Report for Sherwood Forest Hospitals NHS Foundation Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT
July 2013
Appendix V:
Contents
1.
Introduction
3
2.
Background to the Trust
7
Context
7
Trust size and services
7
The Trust’s population
7
3.
Key Lines of Enquiry
11
4.
Review findings
13
5.
Governance and leadership
17
Clinical and operational effectiveness
25
Patient experience
36
Workforce and safety
41
Conclusions and support required
Appendices
Focus groups held
64
Appendix VI: Information available to the RRR panel
65
Appendix VII: Unannounced site visit
73
47
54
Appendix I:
SHMI and HSMR definitions
55
Appendix II:
Panel composition
57
Appendix III:
Interviews held
59
Appendix IV: Observations undertaken
61
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1. Introduction
This section of the report provides background to the review process and details of the key stages of the review.
Overview of review process
On 6 February 2013, the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by
those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the
basis that they have been outliers for the last two consecutive years on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised Mortality
Ratio (HSMR). Definitions of SHMI and HSMR are included at Appendix I.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1) Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the
patients in each of the hospitals and also considered independent feedback from stakeholders related to the trust being reviewed, which had been received through the
Keogh review website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the
interest of patients first at all times.
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid
responsive reviews and risk summits. The process was designed to:

Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these trusts.
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
Identify:
i.
Whether existing action by these trusts to improve quality is adequate and whether any additional steps should be taken.
ii.
Any additional external support that should be made available to these trusts to help them improve.
iii.
Any areas that may require regulatory action in order to protect patients.
The review follows a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/sherwood-forest-data-packs.pdf.

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed
the hospital in action. This involved walking the wards and departments, and interviewing patients, trainees, staff and Board members. This report sets out the panel’s
findings from this stage to be considered at the risk summit.

Stage 3 – Risk summit
This will bring together a separate group of experts from across health organisations, including the regulatory bodies. They will consider the report from the RRR, alongside
other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the
hospitals concerned. A report following each risk summit will be made publically available.
Methods of Investigation
The two day announced RRR visit took place at the King’s Mill Hospital and Newark Hospital, the two acute hospital sites of Sherwood Forest Hospitals NHS Foundation
Trust (“the Trust”), on Monday 17 and Tuesday 18 June 2013. A variety of review methods were used to investigate the KLOEs and enable the panel to consider evidence
from multiple sources in making their judgements.
The visit included the following methods of investigation:

Listening events
Public listening events give the public an opportunity to share their personal experiences of the Trust, and to voice their opinion on what they feel works well or needs
improving at the Trust. Listening events for the public and patients were held on the evening of Monday 17 June in Mansfield (King’s Mill Hospital) and Newark (Newark Town
Hall). These were open events, publicised locally, and attended by approximately 50 and 120 members of the public and patients respectively.
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The panel would like to thank all those attending the listening events who were open with the sharing of their experiences and balanced in their perceptions of the quality of
care and treatment at the Trust. The panel found the listening events extremely useful as it identified a number of positive themes around patient experiences, along with
highlighting a number of areas for further investigation.
Information obtained about the quality of care and treatment at the Trust from the listening events was used to drive the panel's agenda for the second day of the announced
site visit and for the unannounced site visit. Relevant themes emerging have been included within this report.

Interviews
17 interviews took place with key members of the Executive team, Non Executive Directors and selected members of staff based on the KLOEs during the visits. One further
interview was held after the announced visit and prior to the unannounced visit. Two additional interviews were held the following week due to staff absences during the week
of the announced and unannounced visits. See Appendix III for details of the interviews undertaken.

Observations
Observations of clinical areas and meetings enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their
families where observations took place during visiting hours. They allowed the panel to speak with a range of staff and assess any observed handover processes within
wards, to ensure that the staff that were coming on duty were appropriately briefed on patients.
During the RRR announced visit, observations took place in 30 areas and of one bed meeting of King’s Mill Hospital and 6 areas of Newark Hospital. A panel member also
observed the Clinical Governance & Quality Committee on Wednesday 18 June. See Appendix IV for details of the observations undertaken.
Further observations were undertaken as part of the unannounced site visit, see below.

Focus Groups
Focus groups provided an opportunity to talk to staff groups individually to ask each area of staff what they feel is good about patient care in the Trust and what needs
improving. They enabled staff to speak up if they feel there is a barrier that is preventing them from providing good quality care to patients and what actions might the Trust
need to consider to improve, including addressing areas with higher than expected mortality indicators.
Focus groups were held during the announced site visit at King’s Mill Hospital with six staff groups, including a focus group open to all staff. A focus group was also held with
the Trust’s Governors. See Appendix V for details of the focus groups held.
The panel would like to thank all those who attended the focus groups and were open with the sharing of their experiences and balanced in their perceptions of the quality of
care and treatment at the Trust.
5

Review of documentation
A number of documents were made available to the panellists by the Trust as part of the RRR. Whilst the documents were not all reviewed in detail, they were available to
the panellists to validate findings. See Appendix VI for details of the documents available to the panel.

Unannounced visit
The unannounced site visit took place on the evening of Thursday 20 June 2013 at King’s Mill Hospital and Newark Hospital. This focused on areas identified at the
announced site visit. The unannounced visit included meeting with the site managers at both sites and observation of areas within the two hospitals and handover meetings
held during the unannounced site visit. See Appendix VII for details of the agenda completed.
Next steps
This report has been produced by Dr David Levy, Panel Chair with the full support and input of panel members. The RRR findings contained in this report have been agreed
with the Trust for factual accuracy. This report was issued to attendees at the risk summit, which focussed on supporting Sherwood Forest Hospitals NHS Foundation Trust
(“the Trust”) in addressing the actions identified to improve the quality of care and treatment.
Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising
from the 14 investigations will also be published. On 16 July 2013.
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2. Background to the Trust
This section of the report provides background information on the Trust.
Context
The Trust is located in Nottinghamshire and services a population of 400,000 people in and around Mansfield, Ashfield, Newark and Sherwood. It became a Foundation Trust
in 2007. The Trust has a total of 744 beds and offers a large range of services. In 2012, the Trust treated a total of almost 85,000 inpatients, as well as almost 391,000
outpatients.
It has two main acute hospitals sites, the King’s Mill Hospital in Ashfield, and Newark Hospital. Over £320 million has been invested in the new facilities at the new PFI build
at King’s Mill Hospital and the hospital offers over 550 bed spaces as well as an accident and emergency (A&E) service. Newark Hospital has 35 beds available across two
medical wards and a further 21 more in the surgical ward along with a minor injuries unit (MIU). The A&E department at Newark (which did not provide a surgical or trauma
service) was downgraded to an MIU in 2011 following a consultation, due to safety issues predominately related to medical staff cover.
The Trust had a net deficit in its 2012/13 budget of £15 million primarily due to the cost of the PFI and Monitor intervened at the Trust in October 2012 due to finance and
governance breaches.
A review of ambulance response times showed that East Midlands Ambulance Service fails to meet both the 8 minutes and the 19 minutes national response targets and is
the worst performing ambulance trust in England on both measures in 2012.
The Trust was placed in breach with Monitor for finance and governance in October 2012. As a result an interim Chair and Chief Executive were appointed at that time.
The Trust’s HSMR was above the expected level in 2010/11 and 2011/12, and the Trust was therefore selected for this review. The Trust’s SHMI is statistically within the
expected range in the same period.
Trust size and services
It is a medium sized trust for both inpatient and outpatient measures of activity, relative to the rest of England. General medicine and gynaecology are the largest inpatient
specialties while trauma and orthopaedics and ophthalmology are the largest for outpatients.
The market share of the Trust for inpatient activity is 69% within a 5 mile radius, falling to 37% within a 10 mile radius, and 9% within a 20 mile radius. Its main competitors are
Nottingham University Hospitals NHS Trust, United Lincolnshire Hospitals NHS Trust, Derby Hospitals NHS Foundation Trust, Circle and Chesterfield Royal Hospital NHS
Foundation Trust.
The Trust’s population
In Nottinghamshire, 4.5% of the population belong to non-white ethnic minorities; Indians constitute the largest single minority with 0.9%. Smoking in pregnancy is the single
largest health-related concern in the Trust’s local area, where the proportion of the population gaining at least a C in five or more GSCEs is also significantly lower than in the
country as a whole.
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Key messages from the data analysis
1
The Trust data pack identified a number of key concerns that were used to inform the KLOEs for the RRR, which are outlined below .
Mortality
The Trust has an overall HSMR of 116 for the period January 2012 to December 2012, meaning that the number of actual deaths is higher than the expected level. This is
statistically above the expected range.
The Trust’s HSMR during the week and at the weekend is higher than expected at 114 and 123 respectively. This is due to non-elective admissions, as opposed to elective
admissions which are within the expected HSMR range at 54.
Mortality from both week and weekend admission are highlighted by the analysis as being above expected level, due to the high non-elective admissions.
Within non-elective admissions, general medicine and obstetrics have an HSMR higher than the expected level. Analysis of the data over the period January to December
2012 identified the following diagnostic groups in general medicine with the greatest number of above expected deaths as: septicaemia (except in labour); pneumonia (except
that caused by tuberculosis or sexually transmitted disease); acute cerebrovascular disease; urinary tract infection (UTIs); and acute and unspecified renal failure. As
obstetrics had only three observed deaths above the expected level there were no diagnosis groups highlighted for the review by the data.
The Trust has a SHMI of 108 for the period December 2011 to November 2012. This is statistically above the expected range based on the 95% confidence intervals of the
Poisson distribution but within the expected range for the Health and Social Centre Information Centre’s (HSCIC) broader confidence intervals for the year to September
2012. As with HSMR, this is due to non-elective admissions which are above the expected range at 109, as opposed to elective admissions which are within range at 82.
General medicine is the only specialty with a SHMI significantly above expected (110) with 148 observed deaths. The diagnostic groups of septicaemia and acute
cerebrovascular disease are the main groups with higher than expected deaths.
The Care Quality Commission (CQC) mortality alerts issued since 2007 show sepsis and emergency care as common themes, with two alerts specifically for septicaemia
(except in labour).
The Trust put in place a sepsis action plan to address the issues found and developed a Mortality Work Streams action plan in response to their elevated HSMR.
The key lines of enquiry (KLOEs) for the RRR included a review of the specialities in the Trust with higher mortality indicators and these informed the panel’s
observations and interviews.
Governance and leadership
Prior to October 2012, there was a high turnover of Chief Executives at the Trust and the focus of the Trust Board was more on financial issues rather than quality of care.
Following Monitor’s intervention in October 2012, there were a number of changes to the Trust Board, including the appointment of an interim Chief Executive and Chairman,
and a number of new Non-Executive Directors from May 2013. The interim Chief Executive stated that, on arrival, he found the Board to be dysfunctional and the governance
processes in need of urgent review. A formal review was undertaken of governance arrangements by PricewaterhouseCoopers and a review of the financial position was
1
For further information and explanations on the data analysis used please see the published data pack at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx.
8
undertaken by KPMG. Further reviews have recently been undertaken by both PricewaterhouseCoopers and KPMG in May 2013, primarily focused on reviewing the progress
made since the initial reviews.
The Trust has now recruited permanently to the posts of Chief Executive and Chair. The new permanent Chief Executive, Paul O’Connor, and the permanent Chairman,
Sean Lyons commenced on 10 June 2013.
The Board sub-committee with responsibility for quality governance is the Clinical Governance & Quality Committee. This sub-committee is chaired by a Non-Executive
Director with a clinical background.
A recent review by the CQC has identified moderate concerns in relation to outcome 16 (assessing and monitoring the quality of service provision).
Key risks for the Trust relate to loss of confidence in the Trust leading to a reputational risk, quality governance, board stability and leadership, financial performance
(including cost improvement programmes), use of agency and temporary staff, and staff sickness.
A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard KLOE for the review.
Clinical and operating effectiveness
In the National Clinical Audit for Neonatal intensive and special care (NNAP), a key measure of effectiveness is the percentage of women receiving ante-natal steroids. On
this measure, the Trust is at the lower end of the distribution, and some way short of the national average. The Trust acknowledges that completion of the badger database to
date has been unacceptable and states that it is rectifying this. The Trust states it has evidence that it is achieving 95% via the Trent Neonatal Network.
The Trust saw 94.7% of A&E patients during the period January to December 2012 within 4 hours which was slightly below the 95% target level. Performance had been
decreasing over the period July 2012 to December 2012. At the time of the review, the Trust states that performance of 96.4% had been achieved in quarter 1 (April to June)
of 2013 and 98.2% in May 2013.
93.8% of patients are seen within the 18 week target time which is above the target level. The Trust’s performance has varied on this measure between April 2012 and
February 2013, but has recently risen just above the target rate.
The Trust’s crude readmission rate is average for readmission rates of the trusts in the review as well as nationally, at 11.3%. The standardised readmission rate shows the
Trust to be within the expected range. It has an average length of stay of 4.7 days, which is shorter than the national mean average of 5.2 days.
The patient related outcomes measures (PROMs) dashboard shows that the Trust was within the 99.8% control limits in all three years for all measures.
A high level review of clinical and operating effectiveness measures was a standard KLOE for the review as was a KLOE to review management of patients to
consider patient flow through the Trust.
Patient experience
The Trust was not rated ‘red’ on any of the nine measures reviewed within patient experience and complaints. These are: inpatient experience; cancer survey; privacy and
dignity; complaints about clinical aspects; environment; food; friends and family test; and patient voice comments. Further the Trust is rated as A-rated by the Ombudsman
which indicates a low risk of non-compliance with their recommendations; although the report noted that it is likely to be downgraded at the next review.
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There were some concerns on the inpatient survey relating to delays on discharge and some negative points around access to research options on the cancer survey. The
patient voice survey included some negative comments related to covering up medical errors, lack of professionalism and lack of compassion. However, overall the Trust
scores well on patient experience measures.
KLOEs were included in the review focusing on what patients say about the quality of care and treatment and what the Trust was doing in response to this
feedback.
Workforce and safety
The Trust has reported more patient safety incidents than similar trusts. Organisations that report more incidents may have a stronger and more effective safety culture. The
Trust is rated ‘red’ on two of the safety measures: medication errors and pressure ulcers.
It has a rate of medication error that is more than three standard deviations from the mean although it should be noted that there is no desired direction for this indicator.
Throughout the 12 months to March 2013, the Trust’s new pressure ulcer rate has been consistently below the national average. However, the total pressure ulcer prevalence
rate has been above the national average in winter.
259 incidents were reported as ‘moderate, severe or death’ from April 11 to March 12 and two ‘never events’ have been recorded at the Trust since 2009.
The Trust is a net contributor to the Clinical Negligence Scheme for Trusts and has only had two flags on the Rule 43 Coroners’ reports since July 2008.
It has flagged red 11 times for the workforce measures. Most notably the Trust has high sickness absence rates and medical staff vacancy rates. It also spends a greater
percentage of its total expenditure on agency staff compared with the regional average.
From the results of the 2011/12 National Staff Survey there are red flags for staff engagement levels, care of patients being the organisation’s top priority and staff
recommending the Trust as a place to work.
The number of doctors in training commenting on patient safety concerns as part of the National Training Scheme was higher than the national average.
The KLOEs for the review included consideration of the issues the data raised around incident reporting, medication errors and pressure ulcers. Standard
KLOEs were included around workforce planning and staff support.
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3. Key Lines of Enquiry
The KLOEs were drafted using the following key inputs:
1. The KLOEs which were included expected areas of focus for all 14 trusts building on the RRR guidance and design work.
2. The Trust data pack produced at Stage 1 (and made publicly available) to tailor the KLOEs to address any areas the Trust was an outlier in, see section 2 for more
details.
3. Insights from the Trust’s lead Clinical Commissioning Group (CCG), Newark and Sherwood CCG.
4. Review of the patient voice feedback received via the Keogh review website, specific to the Trust prior to the site visit.
These were agreed by the panellists at the panel briefing session prior to the RRR visit.
The KLOEs identified for the Trust were as follows:
Theme
Key Line of Enquiry
Governance and leadership
1.
Can the Trust clearly articulate its new governance processes for assuring the quality of treatment of care? Are the leadership roles and
responsibilities clearly defined for the quality processes? Can staff at all levels of the organisation describe the key elements of the quality
governance processes?
Clinical and operational effectiveness
2.
What governance arrangements does the Trust have to monitor clinical and operational performance data at a senior level? What processes
does the Trust have in place to support monitoring mortality data and clinical effectiveness? Has the Trust data identified any issues? What
actions is the Trust taking to address issues noted?
3. How does the Trust manage patient admissions, care and flow through the hospital? Has the Trust identified any issues? What actions is
the Trust taking to address issues noted?
4. How does the Trust manage general surgery?
5. How does the Trust manage deteriorating patients? Has the Trust identified any issues with the management of deteriorating patients? What
actions is the Trust taking to address issues noted?
Patient experience
6.
How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themes
from patients on their experiences? What action is it taking to address the key themes emerging? What do patients say about the quality of
care in the Trust during our observations/interviews?
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Theme
Key Line of Enquiry
Workforce and safety
7.
How does the Trust approach workforce planning to ensure that patient safety is managed effectively including skill mix? Is there effective
provision for surgical and medical consultant input following admission?
8. How does the Trust support its staff including with adequate training?
The KLOEs were used by the RRR panel to focus the visit and ensure that the key concerns raised by the data pack were addressed. However, where concerns were
identified within the areas of focus, the panel ensured that these were also investigated as far as time allowed.
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4. Review findings
Introduction
The following section provides a detailed analysis of the panel’s findings, including good practice noted, outstanding concerns and prioritisation of actions required by KLOE.
No issues were identified during the course of the review that were considered by the panel, with the support of the CQC representative on the panel, to need immediate
escalation and resolution.
A high level summary of the areas identified for urgent action are as follows:
Leadership and governance

Development of a focus on quality at Board level
The Trust has had instability at Board level, particularly the Chief Executive and the focus of the organisation has been financial and meeting Monitor breaches in finance
and governance. Quality had been moved to an early part of the Board agenda and quality dashboards were being developed. However, during the RRR process, the
panel observed that a Board level focus on quality and the patient was still developing. There was no evidence of patient stories going to Board, poor compliance with the
complaints process and the Board appeared focused on mortality rather than wider quality issues. Further work was required to develop the focus on quality and the
patient at Board level including widening the focus on mortality to consider quality and safety and patient stories to be heard at the Board.

Need for a clear strategic direction for the Trust including use of Newark Hospital
There were lots of good practices identified throughout the Trust but these appeared to be ward level specific. There was an absence of a strong strategic direction and
Trust level working. All the Trust’s strategic plans were either in draft or not yet in place. This was also seen through the absence of a clear strategy for Newark Hospital
with no clearly articulated future use for the hospital and best use of the facilities there. There is an ongoing plan to examine the services being provided at Newark
Hospital and develop the strategy for the site. There was a recognition that strategy development needs to engage the local population and press. It was also unclear
how the Trust was engaging with their local healthcare economy partners. The Trust needs to determine and clearly articulate and communicate its strategic direction,
including the use of the facilities at Newark Hospital and ensure that the facilities are adequate for the services to be provided at Newark Hospital and kept under constant
review to provide ongoing assurance.

Governance of Newark Hospital
Concerns were identified with the effectiveness of the governance of the hospital with a governance group meeting at Newark Hospital but with an apparent self review
agenda and no clear way for this group to feed into the Trust governance structure other than send information to three different governance groups. In view of the
concerns about the safety of care at Newark Hospital, it should be identified as a separate site within the Trust governance structures as relevant. The Executive lead for
Newark Hospital needs to be more visible at the hospital and the responsibility clearly communicated throughout the Trust. In view of the on-going concerns about
mortality rates for Newark residents, the CCG and Trust need to set up a group to review the data and understand if there are any underlying concerns that should be
addressed.
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Clinical and operational effectiveness

Processes to understand ward level performance were missing
Concerns were noted around performance information including the absence of ward level performance measures and information. Staff were generally unable to
articulate performance levels on their own wards. At Trust level, the Quality Report did not appear to have systematic processes to support it. Consistent ward
dashboards are needed across the Trust presenting relevant ward level performance measures and up to date performance data. Ward dashboards should be supported
by ward level assurance processes to ensure the accuracy of the data, for example by quarterly data audits.

Concerns about the whistle blowing policy
The whistle blowing policy contained no approval or review date. The policy also appeared to imply that staff who blew the whistle would be monitored as it contained the
statement “A file of any whistle-blowing concern will be kept on the member of staff’s personal file”. Staff who blow the whistle should not be monitored. The policy
should be updated to confirm this.

Absence of effective organisational learning processes and systems
Due to professional silos across specialties and sites, there was an absence of effective organisational learning processes and systems in response to complaints,
serious incidents or good practices. Staff interviewed spoke of concerns raised not being acknowledged and there being no feedback from incidents reported. The Trust
should implement systems to ensure organisational learning from good practice, concerns and incidents lead by an Executive.

There are high numbers of patient moves and high pairings for outliers
During the RRR process, concerns were identified over the number of patient moves and outliers within the Trust. There was also a high number of pairings for outliers
indicating culture of acceptance of outliers. Patients were also being ‘lost’ in this system. The Trust should risk assess all patients prior to a move or transfer.

Backlog of complaints and clinic letters
Patients were experiencing significant delays in receiving discharge letters and clinic appointments. At the time of the RRR, the Trust had a significant backlog of
complaints, including complaints dating back to 2010. There was no identified sustainable plan to either address the backlog or prevent the issue reoccurring.
Support staff levels and roles need to be to be reviewed. An increase in the pace of change is required to address the backlogs. Sustainable plans are needed for
complaints, discharge letters, clinic appointments and radiology reporting.

Insufficient handover times
It was identified that ward staff only had 20 minutes to hand over patients on shift changes. This meant no one had an overview of all the patients on the ward. A review
of handover times is needed to ensure there is time to handover all patients on the ward adequately.

National early warning system (NEWS) roll out without an updated policy for its use
In relation to deteriorating patients there are concerns about the National early warning system (NEWS) being rolled out without policy about its use. An updated,
comprehensive NEWS policy should be developed and communicated to staff.
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
Concerns about fluid management were identified
Throughout the RRR, the panel identified concerns with fluid management throughout the Trust, through observations and by speaking with patients. Review of fluid
charts identified issues with most reviewed including records not being completed and totalled. There should be frequent audits of fluid management processes and
improvements in fluid management.
Patient experience

Patient experience is a significant area of weakness for the Trust
A number of examples of poor patient experience were identified during the RRR with an apparent absence of the recognition of the patient in the Trust’s priorities and
actions – these focused on Monitor’s requirements, not the patients. The Board does not hear patient stories. The Trust did not appear to have a patient engagement
strategy or systems to engage with and obtain feedback from patients and then act upon it. The Trust needs to develop a patient experience and engagement strategy
with processes and systems to ensure effective collecting and responding to patient feedback, both positive and where areas of improvement are identified.
Workforce and safety

There were questions about safe medical and nursing staffing levels both in-and out-of hours
Significant concerns were noted around staffing levels at both King’s Mill Hospital and Newark Hospital. At King’s Mill Hospital, concerns noted were made more
significant by the design of the hospital which, in a number of areas, prevented staff visibility of patients from central desks. Clinical cover is particularly low at the Newark
site. The concerns were all identified alongside the Trust cost improvement plan (CIP) to reduce staffing in 2013/14.

The nursing skill mix was a significant concern
The Trust stated that nurse trained to untrained ratios were currently 50:50 on the general wards. The minimum that the RRR panel would expect is 60:40 with a
preference for 65:35. The above are made more significant by the design of the hospital impacting on the ability to provide safe care so staffing levels need to consider
the hospital design. An urgent review of the nursing skill mix with immediate plans to ensure that the skill mix in place is adequate to provide safe patient care is needed.
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The following definitions are used for the rating of recommendations in this review:
Rating
Definition
Urgent
The Trust should take immediate action to respond to these recommendations and
ensure improvement in the quality of care
High
The Trust should develop a response and action plan for these recommendations to
ensure improvement in the quality of care
Medium
The Trust should implement these recommendations to ensure ongoing improvement
in the quality of care
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Governance and leadership
Overview
The KLOE in the governance and leadership area was the standard key line of enquiry for the review tailored to consider the understanding and impact of the new quality
governance processes and changes in leadership at the Trust.
Examples of good practice were identified in the following areas:

There are unannounced visits of Executive and Non Executive Directors at King’s Mill Hospital.

There were examples of excellent ward leadership observed.

The June 2013 Clinical Governance & Quality Committee was well chaired and the Non Executive Directors attending challenged the Executives effectively during the
meeting.
The following areas of outstanding concern were identified:

Development of a focus on quality at Board level: The focus of the organisation appears to be financial and meeting Monitor breaches in finance and governance
rather than patients. There was no evidence of patient stories going to Board and poor compliance with the Complaints process, the focus on mortality at the Board does
not equal quality and safety.

Need for a clear strategic direction for the Trust and evidence of silo working throughout the Trust: There are lots of good practices at ward level but no strategies
that outline the overall strategic direction for the trust (for instance the role of Newark); it is also unclear how the Trust engages with their local healthcare economy
partners.

Clarity of governance structures, including how Newark fits in, and gap between ward level and Board level: Governance structure lacks clarity in “Ward to Board”
processes especially in regards to how performance feeds into one another. The governance of Newark is not clear.

Embedding new leadership and maintaining pace of change: It is unclear at present how effective the leadership team are given the appointment of the Chair and
Chief Executive on the 10 June 2013. Changes need to embed and the pace of change needs to be maintained.

Concerns noted over the access and effectiveness of Governors: Governors stated that they felt that they had been alienated by the Trust and feel unable to do their
roles effectively.
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Detailed Findings
Governance and leadership
KLOE 1: Can the Trust clearly articulate its new governance processes for assuring the quality of treatment of care? Are the leadership roles and responsibilities clearly
defined for the quality processes? Can staff at all levels of the organisation describe the key elements of the quality governance processes?
Good practice identified
We were informed that there were unannounced visits of King’s Mill Hospital areas by Non Executive Directors and also Executive team walkabouts at King’s
Mill Hospital.
The Director of Nursing had nearly established a full team of her own choosing and was observed to be, and noted by some staff to be, very engaged with
King’s Mill Hospital. At the time of the review, she was in the process of recruiting for a senior governance support post.
The Associate Medical Director had an impressive vision for mortality reviews, reporting and learning.
There were examples of excellent ward leadership observed, specifically the stroke ward where multidisciplinary team working was well established.
Elements of reporting were observed to be being done well. Examples included having a standard template agenda for each specialty governance meeting, as
well as the existence of a joint nursing and medical report to Board.
Observation of the June 2013 Clinical Governance & Quality Committee identified that the meeting was well chaired and that the Non Executive Directors
attending challenged the Executives effectively during the meeting.
Outstanding concerns based on evidence
gathered
Key planned improvements
i. Development of a focus on quality at Board level Quality has been moved to the early part of the Board
agenda.
During the RRR process, the panel observed that a
Board level focus on quality and the patient was still
The Trust is introducing quality dashboards and the
developing. A number of plans were described by
first draft was shared at the Clinical Governance &
members of the Board as being required by Monitor,
Quality Committee held in June 2013.
rather than being needed to improved levels of quality
and safety, and there was recognition that the Trust
has historically been focused on finance rather than
Recommended actions
Priority –
urgent,
high or
medium
The Board must set a tone from the top of the
organisation to prioritise quality and the
patient. The current focus on mortality to be
widened to consider quality and safety.
Sufficient time should continue to be given to
quality issues at the Board.
Urgent
Directors responsibilities should clearly
High
18
Outstanding concerns based on evidence
gathered
Key planned improvements
quality.
It was identified that the Board does not currently hear
patient stories. It was also observed that the Board
appeared to be focused on mortality issues rather
than wider quality issues. An example of the focus on
finance was the Stroke Review Board paper of July
2012 that contained an analysis of the planned
changes from an income point of view only, not a
quality perspective.
The need to further develop the quality focus of the
Board was confirmed through review of the Executive
team’s responsibilities which identified the following
issues:
 The Director of Operation’s job description
appeared to be primarily finance, rather than
quality or patient, focused.
 The Director of Nursing has a heavy responsibility
for governance improvements which may impede
on quality responsibilities.
Recommended actions
Priority –
urgent,
high or
medium
articulate their quality responsibilities and be
balanced to enable sufficient time to be given
to these.
The Board should hear a patient story at
every Board meeting and consider and
cascade across the organisation the lessons
learned as a result.
High
Board away day development to develop
quality and transformation strategy. Board
away day time to review quality governance
and align this to annual business planning.
High
Improvement trajectories need to be set with
a range of KPIs (key performance indicators)
and run charts that underpin the overarching
strategy for HSMR reduction.
High
The Trust needs to determine and clearly
articulate and communicate its strategic
direction, including the use of the facilities at
Urgent
The quality governance framework was seen as a
parallel exercise by the PMO (programme
management office) opposed to embedding as a
collective Board responsibility.
The absence of a patient safety programme was stark
to underpin the strategic intent of an HSMR 10%
reduction which was described as an arbitrary aim.
ii. Strategic direction
The Trust is currently refreshing its strategies
including:
Whilst the panel observed a number of good practices  Clinical and Quality strategies, which it is
throughout the Trust, these appeared to be ward level
19
Outstanding concerns based on evidence
gathered
specific and silo-ed. Whilst the Trust does have an
annual plan signed off by the Board, there was an
absence of a strong strategic direction and Trust level
working. This was confirmed by a number of nurses
interviewed who stated that if felt like wards worked in
silos and no one had an effective umbrella role across
the Trust.
All the Trust’s strategic plans and strategies were
either in draft or not yet in place. There were no
robust clinical or quality strategies in place at the Trust
at the time of the RRR. The Trust had no nursing
strategy and nurses attending the focus group were
unclear as to the strategic priorities of the Trust or
their contribution to improving standards and quality.
This was also seen through the absence of a clear
strategy for Newark Hospital with no clearly articulated
future use for the hospital and best use of the facilities
there.
Key planned improvements






anticipated will connect to each other.
Data strategy.
IT strategy.
Workforce strategy.
Organisational development strategy.
Communications strategy.
Nursing strategy.
There is an ongoing plan to examine the services
being provided at Newark Hospital and develop the
strategy for the site. There is a recognition that the
strategy development needs to engage the local
population and press.
Recommended actions
Priority –
urgent,
high or
medium
Newark Hospital.
The Newark strategy needs to determine the
future of the hospital working with the wider
health community and social care and the
public.
Urgent
Immediate discussions to consider including
Nottinghamshire University Hospitals as a full
partner in the Mid Nottinghamshire Review.
Urgent
See also recommended actions below at (iv)
maintaining the pace of change, specifically
Board effectiveness reviews and Board
development.
It was also unclear how the Trust was engaging with
their local healthcare economy.
Furthermore, the panel saw very limited engagement
with staff and the local population on strategy. The
latter has resulted in public dissatisfaction with the
delivery of care at Newark in particular.
Whilst the Mid Nottinghamshire Review is underway
across the local healthcare economy, the strategy
lacks the full engagement of a tertiary centre. Without
this the options for the Trust are limited.
20
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
iii. Clarity of governance structures and gap
between ward level and Board level
The Trust is planning a review of the clinical
governance committee.
Urgent
Throughout the RRR visit, the panel struggled to
understand the governance structures at the Trust in
particular how certain committees and groups fed into
the Board subcommittee structure. The panel were
unable to obtain this understanding through the
interviews held.
The clinical governance structure has been reviewed
and the Trust is implementing changes to the
governance arrangements in accordance with the
external review action plan.
In view of the concerns about the safety of
care at Newark Hospital, it should be
identified as a separate site within the Trust
governance structures. The Executive lead
for Newark Hospital needs to be more visible
at the hospital and the responsibility clearly
communicated throughout the Trust.
In view of the on-going concerns about
mortality rates for Newark residents, the CCG
and Trust need to set up a group to review
the data and understand if there are any
underlying concerns that should be
addressed.
Urgent
The governance structure should be clearly
articulated and communicated including how
each working group and forum feeds into and
up to the Board and how Newark Hospital
forms part of the Trust governance.
High
Early and effective comprehensive induction
of new appointments throughout the Trust,
including the new Board members supported
by effective Board review and development.
High
See also outstanding concern regarding complaints
under KLOE 6(i).
A particular issue was noted around the governance
of Newark Hospital. Concerns were identified with the
effectiveness of the governance of the hospital with a
governance group meeting at Newark Hospital but
with an apparent self review agenda and no clear way
for this group to feed into the Trust governance
structure other than send information to three different
governance groups as relevant.
Interviews with some staff identified that they were
unable to articulate the Trust’s quality priorities
demonstrating a gap in communication from the Board
to ward level.
See also KLOE 2 outstanding concern (i) regarding
performance information at ward level
iv. Maintaining the pace of change
The Trust has had instability at Board level,
particularly at Chief Executive, over a period of time.
The interim Chief Executive and Chair from October
Substantive appointments have been made to Board
including four new Non Executive Directors
commencing in May 2013 and the Chief Executive and
Chair taking up their posts on 10 June 2013. The final
Non Executive Appointment will become substantive in
21
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
2012 talked of completing phase 1, stabilisation of the
organisation by March 2013, and the plan to move to
phase 2, transformation and transition during 2013/14.
The transformation agenda was not well understood
by staff and how it would be delivered and in what
timescale. The skill set of frontline staff in quality
improvement and transformation was very limited.
November 2013 and was acting in a Non Executive
Advisor role until that date.
Systematic Board Governance Assurance
Framework and build in discussion regarding
the effectiveness of Board at each meeting
including whether any new risks have been
identified. To be supported by Board
development for the Board as a whole and
individual Board members.
High
A third phase, stability, was planned to commence in
2015.
There was a need for the new leadership to quickly
get up to speed and maintain the pace of change set
by the interim leadership to ensure that the Trust
continues to address key issues and concerns.
Board engagement as widely as possible with High
staff groups to both emphasise and energise
the importance of the transformation and to
engage staff in the changes.
Clear and costed training plan to deliver
transformation agenda.
v. Board leadership development
With the Chair and Chief Executive only having taken
up their posts as of 10 June 2013, it was not possible,
at the time of the RRR, for the Trust to demonstrate
the effectiveness of the leadership at the Trust. It was
noted that the outgoing interim Chair was visible and
an active part of the leadership during the RRR
demonstrating a good handover process to the
incoming Chair.
Concerns were noted over the quality and visibility of
the medical leadership at the Trust by patients and the
public.
Increased transparency had been identified as an area
for immediate improvement within the Trust. The Trust
and CCG are planning to hold public Board meetings
in Newark and one in three Board meetings are to be
held in public.
High
On a rotation basis, a member of the
High
Executive team should be regularly based at
Newark Hospital and Non Executive Directors
and Governors should regularly visit that
Hospital.
Every Board meeting to include a public
session.
Medium
See also recommended actions above at (iv)
maintaining the pace of change, specifically
Board effectiveness reviews and Board
development.
Furthermore, the Executive team appeared to be
working in silos, in particular we identified limited
22
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
The new Lead Governor articulated a commitment to
improvements at the Trust including plans for a skills
audit of the Non Executive Directors and a review of
subcommittees and skills training for Non Executive
Directors.
The Trust to work with the Governors to
transform their role to enable them to support
the Trust more effectively and effectively hold
the Trust Board to account including through:
 Having open access to the Trust.
 Provision of papers at least a week prior
to meetings.
 Provision of accurate and completed
minutes within two weeks of meetings.
 Response to information requests within
High
examples of strategic joint working between the
Medical Director and Director of Nursing. Additionally,
the consultant body stated that they did not meet to
support Medical Director leadership and agenda.
There was also limited Executive team engagement
with Newark Hospital with staff there speaking of
limited Executive team presence at the site.
Furthermore, the RRR panel were concerned about
the ownership of assurance by the leadership of the
Trust with interview responses identifying a perceived
reliance on the PMO rather than a clear ownership of
assurance by the Board members themselves.
Issues were noted over Board papers which generally
appeared to provide reassurance rather than
assurance. The papers generally provided narrative
rather than evidence and demonstration of actions
required or being taken, together with any
recommendations. It was further noted that Trust
Board only meets in public quarterly.
vi. Governors
The Governors focus group identified a number of
concerns, including:
 Late provision of information to the Governors
which has, latterly, resulted in their feeling the
need to resort to using Freedom of Information
The new Chair has asked the Clinical Governance &
requests to get information they required in a
Quality Committee to invite a Governor to the
timely manner. Examples included the trust
committee.
taking 14 months to provide information requested
on bed ratios. It was also noted that minutes were
not provided promptly after meetings. The ‘typical’
23
Outstanding concerns based on evidence
gathered


time for minutes to arrive was quoted at two and a
half months, with papers for minutes rarely
arriving a week prior to meetings and thereby not
allowing sufficient time for review.
The records of meetings are incomplete.
Examples included brief summaries of lengthy
discussions and minutes of meetings not including
more challenging actions (towards the Trust).
Insufficient access to the Trust. The Governors
stated that they were not permitted to undertake
unannounced visits to the Trust or speak to
patients without agreement.
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
two weeks of the request.
The Governors spoke of feeling managed and not
being equipped to hold the Trust to account.
It was further noted that, during interviews, the
Executive team stated that the Trust obtains
information on the patient experience from the
Governors.
24
Clinical and operational effectiveness
Overview
The four KLOEs in the clinical and operating effectiveness area focused on governance and monitoring, management of patient flow from admission to discharge,
management of general surgery and management of deteriorating patients.
Examples of good practice were identified in the following areas:

Evidence of an outward looking Trust working with neighbouring trusts and sharing good practice and joint working with other organisations to improve A&E.

The stoma nurses and colorectal cancer nurse specialists were cited to provide excellent continuity of care, especially in combination with the ambulatory clinic on the
Surgical Assessment Unit, if there are concerns. The stoma nurses support to Newark was praised at the Patient Listening event.

The outreach team are very highly regarded by Trust staff.
The following areas of outstanding concern were identified:

Processes to understand ward level performance are missing.

Concerns were identified with the incident and whistle blowing policies. Due to professional silos across specialities and sites, there are no effective organisational
learning processes and systems in response to complaints, serious incidents or good practices.

There are high numbers of patient moves and high pairings for outliers, indicating culture of acceptance of outliers. Patients are also being ‘lost’ in this system.

It was identified that ward staff only had 20 minutes to hand over patients on shift changes. This meant no one had an overview of all the patients on the ward.

There were a number of concerns with the infrastructure in place including significant delays in discharge letters and clinic appointments due to poor use of IT
organisationally to aid record keeping and communications.

The panel were concerned about the triaging of patients within A&E. Escalation of patients was initially reliant on the patients themselves and the receptionists. It was
further noted that there was a lack of oversight of the A&E waiting room as the receptionists did not have a clear line of sight over a large proportion of the waiting area
and the panel observed no clinical observation of the area. It was noted that the Trust aims to see all patients within 15 minutes for triage by a nurse.

The panel observed and heard from patients, that medication was not being received appropriately.

Concerns over infection control were identified including poor access to hand gel throughout the Trust.

There are concerns about the use of the Newark site and the facilities available there in relation to major surgery (joint replacements) and levels of clinical cover to
support the operative and post-operative environments.

There are concerns about anaesthetists’ lack of formal input to the pre-operative assessment process and lack of a lead for day surgery.

In relation to deteriorating patients there are concerns about the NEWS being rolled out without policy about its use.
25

Concerns about fluid management were identified.

There are also concerns about the trust’s ability to rescue patients with DNR (do not resuscitate) forms not being signed by consultants.
Detailed Findings
Clinical and operational governance and monitoring
KLOE 2: What governance arrangements does the Trust have to monitor clinical and operational performance data at a senior level? What processes does the Trust have in
place to support monitoring mortality data and clinical effectiveness? Has the Trust data identified any issues? What actions is the Trust taking to address issues noted?
Good practice identified
There were examples of internal audit being done well through the use of the 15 steps and cardiac arrest audits
The electronic prescribing pilot in Obstetrics and Gynaecology has been well received by junior doctors. Feedback from staff identified that it has been considered easier to
get hold of the right antibiotics since introduction of the sepsis package.
There was evidence identified of an outward looking Trust working with neighbouring trusts and sharing good practice, for example working on the Paediatric Early Warning
Score indicator.
The development of the “Guardian of care and quality” initiative.
Outstanding concerns based on evidence gathered
Key planned
improvements
Recommended actions
Priority –
urgent, high
or medium
i. Ward performance information
None noted
Consistent ward dashboards across the Trust
presenting relevant ward level performance
measures and up to date performance data.
Ward dashboards to be supported by ward level
assurance processes to ensure the accuracy of
the data, for example by quarterly data audits and
regular minuted ward meetings.
Urgent
The Trust uses a system to rank wards within King’s Mill Hospital and observations
of the top and bottom ranked wards verified the accuracy of the rankings.
However, concerns were noted around performance information including the
absence of ward level performance measures and information on many wards.
Staff were generally unable to articulate performance levels on their own wards, for
example the number of falls on the ward in the last month. Interviews with staff
generally identified that staff were unaware of performance levels and did not feel
Review of the Trust decision to remove ward white High
boards.
26
Outstanding concerns based on evidence gathered
Key planned
improvements
ownership of them. Examples were noted during observations of out of date ward
performance measures on display on wards or template reports with no information
/ data displayed.
The RRR panel were informed that a decision had been taken to remove ward
based white boards used to manage patients on the ward. Some wards were seen
to have retained theirs and these wards were generally observed to have high
quality care with the white boards being used as a focus for multidisciplinary
meetings.
Recommended actions
Priority –
urgent, high
or medium
A quality strategy to support the completion of
routine triangulated quality reports incorporating
patient safety, patient experience and clinical
effectiveness.
High
A comprehensive patient safety programme to
enable staff to understand how process and
outcome measures aid the delivery of an HSMR
reduction.
Medium
Staff who blow the whistle should not be
monitored. The policy should be updated to
confirm this.
Urgent
The incident reporting policy should be owned by
an Executive lead.
High
The whistle blowing policy should be updated with
the date last reviewed and regularly reviewed.
Medium
Systems to ensure organisational learning from
good practice, concerns, complaints and incidents
lead by an Executive.
Urgent
Adaptation of the resuscitation audits into the
deteriorating patient work. Consider linking the
resuscitation officer to the outreach team, as
High
At Trust level, the Quality Report did not appear to have systematic processes to
support it. The Quality and Safety Report for May 2013 stated that there was “no
evidence of increased mortality at weekends” whilst the HSMR data shows a
significant increase in mortality at the weekend.
ii. Incident reporting and whistle blowing policies
None noted
Concerns were identified with the incident and whistle blowing policies as follows:
 The incident reporting policy appeared to be owned by the Evaluation and
Research Manager.
 The whistle blowing policy contained no approval or review date. The policy
also appeared to imply that staff who blew the whistle would be monitored as it
contained the statement “A file of any whistle-blowing concern will be kept on
the member of staff’s personal file”.
 Fall reporting was identified as inconsistent and staff interviewed could not
consistently define what they would report as an incident.
 A junior doctor in the focus group suggested that concerns about a more senior
colleague were dealt with in a delayed manner.
iii. Organisational learning
Concerns were noted with the processes in place for organisational learning within
the Trust, including:
 Staff interviewed spoke of concerns raised not being acknowledged and there
being no feedback from incidents reported.
 The incident reporting policy states that the Evaluation Audit and Research
None noted
27
Outstanding concerns based on evidence gathered





Key planned
improvements
Manager, in conjunction with the division and service leads, is responsible for
ensuring that lessons learned are disseminated.
The mortality action plan reviewed was incomplete.
No link had been made by the Trust between the work done by the resuscitation
officer’s analysing all arrest calls and failures to rescue and the outreach team.
A number of staff interviewed stated that they had been told to be circumspect
in what they told the RRR panel.
No quality improvement methodology or knowledge was identified to support
organisational development ambitions.
The backlog in complaints handling has made it impossible to use the feedback
and the lessons learnt from complaints to improve service design and practice.
Recommended actions
Priority –
urgent, high
or medium
minimum the teams should work closely together.
Organisational development programme in quality High
improvement leadership and skills linked to patient
safety programme.
Management of patient flow from admission to discharge
KLOE 3: How does the Trust manage patient admissions, care and flow through the hospital? Has the Trust identified any issues? What actions is the Trust taking to
address issues noted?
Good practice identified
There is ongoing development of ambulatory care in the Trust.
Fernwood Ward was noted to be an impressive new step up-step down service.
The maternity escalation procedure appeared to be working well based on feedback from staff interviewed.
The quality of care provided by the Stoma nurses supporting Newark Hospital was highly praised by patients attending the listening event in Newark.
Joint working with other organisations through the Urgent Care Board was identified to have improved A&E, for instance work on the detailed pathway work with East
Midlands Ambulance Service had significantly reduce ambulance handover waits.
During the unannounced visit, the panel observed a consultant undertaking a review of all new patients across King’s Mill Hospital as part of his evening ward round. There
are processes in place for weekend ward rounds to review new patients and anywhere there is a nursing concern.
Paediatric A&E was observed to well set up with a good observation area and few trip hazards.
28
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
i. High numbers of patient locations and moves
The Trust is considering increasing
CDU (clinical decision unit) hours
and expanding ambulatory care.
Risk assess all patients prior to move or transfer
supported by appropriate training.
Urgent
Remodel the bed base.
High
Bed management meetings to include forward
planning to project the number of emergency
admissions and therefore required beds and
patient flow and discharge likely to be required.
Bed meetings to routinely discuss patient safety
concerns and identification of outliers and
escalation areas.
High
Improved patient tracking.
High
During the RRR process, concerns were identified over the number
of patient moves and outliers within the Trust, including:
 A high number of outlier pairings indicating a culture of
acceptance of outliers.
 Patients were not located in appropriate wards or hospitals,
including cases of the apparent use of Newark Hospital based
on the home address of the patient being Newark rather than
the condition presented. It was also identified that medical
outliers placed on an orthopaedic ward due to winter pressures
were still being located in the orthopaedic ward during the RRR
visit in June 2013.
 An example was identified of a patient moved after four months
followed by a further move after only four hours.
 Elective admissions waiting in the waiting room and, in one
instance observed, in a matrons office due to beds not being
available for the patients.
The Trust plans to implement a
patient tracker system.
It was further noted by junior doctors interviewed that it was difficult
to track outlier patients and that patients often “got lost”.
The following causes of poor patient flow were identified:
 Inefficiency of the single point of access leading to multiple
check-ins for patients, particularly for transfers.
 The bed management meeting observed in the morning did not
consider forward planning.
 Patients were sometimes admitted rather than utilising primary
or community care alternatives.
 Low utilisation of theatres at Newark Hospital.
 Elective wards were being used as an overspill for emergency
admissions but the elective cases were not being cancelled.
No evidence was identified of risk assessments being undertaken
29
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
Review of handover times to ensure there is
time to handover all patients on the ward
adequately.
Urgent
prior to patients being moved or transferred.
ii. Handovers
None noted
It was identified that ward staff only had 20 minutes to hand over
patients on shift changes. Observation of one handover during the
unannounced saw that ward staff had to split into two teams for the
handover period to enable sufficient time to handover all the
patients on the ward. This meant no one had an overview of all the
patients on the ward and each half of the ward was being effectively
staffed by only one trained nurse member and one untrained nurse.
Staff interviewed also spoke of having to stay late to ensure proper
handover of staff as the time allowed was insufficient.
iii. Supporting structures and services
A number of issues were noted with the infrastructure in place and
use of it to support good patient flow and high quality care
including:
 Patients were experiencing significant delays in receiving
discharge letters and clinic appointments.
 The Trust had over 2,000 GP plain films or Neuro MRIs to be
reported on as stated at the Clinical Governance & Quality
Committee held in June 2013.
 Poor use of IT with a number of computers observed on wheels
on wards but no observation of these being used.
 Medical equipment appears to be ward based, for example
pressure relieving mattresses. Medical inventory appeared to
be isolated from the clinicians as clinician support to medical
equipment management was limited to some speciality service
areas, not ‘core’ hospital equipment that spans across services,
e.g. beds.
 It was observed, and verified through interviews with staff, that
the layout of the wards at King’s Mill Hospital made it difficult for
nurses to observe patients effectively.
The Interim Director of Strategy,
responsible for complaints, has been
asked to present a strategy to deal
with the backlog of complaints by the
end of June.
Support staff levels and roles to be reviewed.
Urgent
Increase in the pace of change to address the
backlogs. Sustainable plans to be put in place
for managing complaints, discharge letters, clinic
appointments and radiology reporting.
The Trust is continuing to work on a
plan to address the backlog of
complaints to ensure that it is fully
comprehensive.
Review inappropriate pressures on junior
doctors and ensure consent is valid and
appropriately informed by procedure-competent
or procedure-experienced clinicians.
High
The Trust is continuing to work to
respond to complaints as well as the
validation.
Integration of the supporting infrastructure into
processes including:
 Improved use of IT throughout the Trust.
 Increased clinician engagement in
procurement and management of medical
equipment across services.
Medium
Review the linking of buzzers between paired
wards.
Medium
The Trust is working with GPs to
review the information currently
provided on the electronic discharge
summaries and content of clinic
letters.
30
Outstanding concerns based on evidence gathered


Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
Review the A&E triage and observation
arrangements to ensure appropriate
prioritisation of patients and adequate clinical
oversight of the A&E waiting area.
High
Medication charts should be clearly completed
upon admission to detail existing medication for
patients. It should be ensured that patients
receive the appropriate medication when at the
Trust.
High
Buzzers on wards were identified to also sound on the paired
ward making it difficult to identify the source of the buzzer
The Trust states it is increasing
quickly and easily without reference to the board.
support staff whole time equivalents
The attendees of the junior doctor focus group spoke of
(WTE) by 25.
pressure to sign consent forms for operations and procedures
that they had limited experience of and for procedures that they
were not performing.
iv. A&E / Emergency Department
None noted
During the review, it was noted that the emergency department was
extremely busy. The panel observed the department to be well
managed following triage.
However, it was identified that escalation of patients was initially
reliant on the patients themselves and the receptionists. Patients
walking into A&E were asked to let reception know of any chest
pain. If patients did not inform reception of chest pain, they were
seen in the order of arrival. It was noted that the Trust aims to see
all patients within 15 minutes for triage by a nurse.
It was further noted that there was a lack of oversight of the A&E
waiting room as the receptionists did not have a clear line of sight
over a large proportion of the waiting area and the panel observed
no clinical observation of the area.
v. Medicines management
The panel observed and heard from patients, that medication was
not being received appropriately. Patients spoke of bringing their
own medicine with them as they were concerned that they would
not receive existing medication when at the Trust.
None noted
31
Outstanding concerns based on evidence gathered
vi. Infection control
Key planned improvements
None noted
Concerns over infection control were identified during the RRR. A
patient known to have an infection was allowed to sit in the hospital
waiting area in just a robe. The panel also observed poor access to
hand gel throughout the Trust with dispensers empty, hard to locate
or at a high level and therefore inaccessible to some patients and
the public.
Recommended actions
Priority –
urgent,
high or
medium
Review of infection control processes including
location to hand gel throughout the Trust.
Enforcement of the Hygiene code to be part of
routine DIPC reporting.
High
Management of general surgery
KLOE 4: How does the Trust manage general surgery?
Good practice identified
There is a cohesive department of surgeons, with excellent working between nurses and surgeons and a high number of laparoscopic gastrointestinal colorectal surgeons.
Enhanced recovery is embedded in standard operating procedures.
Pre-operative assessment at Newark Hospital offers one stop appointments and good liaisons with surgical teams and booking of operating dates.
There is very good stocking and replenishment of supplies in orthopaedic wards.
The stoma nurses and colorectal cancer nurse specialists were cited to provide excellent continuity of care, especially in combination with the ambulatory clinic on the
Surgical Assessment Unit, if there are concerns.
32
Outstanding concerns based on evidence gathered
Key planned
improvements
Recommended actions
Priority –
urgent, high
or medium
i. Facilities at Newark Hospital
None noted
The Trust to determine, clearly articulate and communicate its
strategic direction on the use of the facilities at Newark Hospital.
Ensure that the facilities are adequate for the services to be
provided at Newark Hospital and keep under constant review to
provide ongoing assurance.
Urgent
None noted
Review anaesthetists’ arrangements to formalise their input into
pre-operative assessment at both hospital sites and
communicate the arrangements to all staff, including:
 A named lead for day surgery.
 Formal session of time for dedicated preoperative
assessment sessions.
 An acute pain clinical session.
 Use of protocols for preoperative management of comorbidities.
High
Major operations (joint replacements) are carried out at Newark
Hospital including on a Friday morning. These operations have the
potential for serious complications and the hospital does not have
adequate facilities should serious complications arise. For example,
there is no blood bank at the hospital.
See also KLOE 7(i) regarding nursing and medical staffing levels,
including concerns over the surgical cover at Newark overnight and at
weekends.
ii. Anaesthetists
Concerns were identified through staff interviews around the working
arrangements for anaesthetists as follows:
 Anaesthetists interviewed did not have dedicated preoperative
assessment sessions.
 No lead for day surgery known by the anaesthetists interviewed.
 No acute pain clinical session for anaesthetists.
 No formal anaesthetist input into the preoperative clinic at Newark
Hospital.
 No use of protocols for preoperative management of comorbidities identified.
33
Management of deteriorating patients
KLOE 5: How does the Trust manage deteriorating patients? Has the Trust identified any issues with the management of deteriorating patients? What actions is the Trust
taking to address issues noted?
Good practice identified
Sepsis bundles that were audited showed improvements. Sepsis is down for the fourth consecutive month. On Ward 35 there were sepsis recognition cards in all patient
notes reviewed and all staff interviewed were trained to use the sepsis box, which was readily available.
The outreach team are very highly regarded by Trust staff.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
i. NEWS roll out
None noted
An updated, comprehensive NEWS
policy should be developed and
communicated to staff.
Urgent
The Trust were employing an
external company in to provide
hydration education and training
to teams.
Training supported by frequent
audits of fluid management
processes and improvements in fluid
management.
Urgent
At the time of the RRR visit, NEWS had been introduced at the Trust and staff
interviewed spoke of the revised process. However, the only policy that the RRR
panel identified was the old policy in tracked changes – no revised policy was
identified to support the introduction of a revised process.
Observations at Newark Hospital identified old APC system cards on the walls
and staff spoke of using their judgement for escalation rather than use of NEWS.
ii. Fluid management
Throughout the RRR, the panel identified concerns with fluid management
throughout the Trust, through observations and by speaking with patients.
Review of fluid charts identified issues with the majority reviewed including: no
records of fluid for patients for a over a day; fluid records not completed; patients
not being risk assessed for fluid on arrival; and fluid balance charts not being
totalled.
In addition, the ‘Red Jug’ initiative being used for patients with a need for
assistance with fluid was not observed to be effective – many patients with an
apparent need for assistance had not been identified.
An implementation project nurse
had been appointed to roll out
Trust wide initiatives.
An Acute Kidney Injury review has
been completed – at the time of
the review, the response had not
34
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
been received.
The Trust is planning to include a
fluid management nurse within the
outreach team.
iii. Ability to rescue
Resuscitation equipment was identified to be in a box – a legacy of an historic
process and out of date with usual hospital practice of comprehensively equipped
trolleys.
Review of ‘do not resuscitate forms’ found many to be signed by junior doctors
with no evidence of a consultant’s signature.
None noted
‘Do not resuscitate’ forms should be High
signed by a consultant. Regular
audits to be performed to ensure that
this is occurring.
Review the policy for resuscitation
equipment and consider updating to
comprehensively equipped trolleys.
Medium
35
Patient experience
Overview
The KLOE in the patient experience area was the standard key line of enquiry focusing on patient experience and engagement.
Examples of good practice were identified in the following areas:

High-quality, personalised care throughout the Trust was reported by many patients and families. Generally patients felt, that once they were seen, they were given very
good care.

There are clean and bright new wards at King’s Mill Hospital.
The following areas of outstanding concern were identified:

Complaints are a significant concern with a significant backlog, no substantive team, no clarity of the numbers outstanding, PALS separated from complaints and no
sustainable plan to resolve the complaints backlog.

Patient experience is a significant area of weakness for the Trust with an apparent absence of the recognition of the patient in the Trust’s priorities and actions – these
focused on Monitor’s requirements, not the patients. The Board does not hear patient stories.

Communication with patients was poor including the nature of responses provided to complainants and communicating with patients during the stay and on discharge.
Detailed Findings
Patient experience and engagement
KLOE 6: How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themes from patients on their
experiences? What action is it taking to address the key themes emerging? What do patients say about the quality of care in the Trust during our observations/interviews?
Good practice identified
High-quality, personalised care throughout the Trust was reported by many patients and families. Generally patients felt, that once they were seen, they were given very good
care. Mothers’ satisfaction is high with relevant services.
The ward host on care of the elderly ward was adored by patients and is making a difference.
There are clean and bright new wards at King’s Mill Hospital.
36
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
i. Complaints
The Interim Director of Strategy,
responsible for complaints, has been
asked to present a strategy to deal with
the backlog of complaints by the end of
June.
The backlog of complaints should be cleared
alongside development of a sustainable
approach to acknowledging and responding to
complaints going forward. This should be lead
by a clinical Executive member of the Board.
Urgent
The Trust is continuing to work on a
plan to address the backlog of
complaints to ensure that it is fully
comprehensive.
High
Reports on complaints and incidents to the
Board should detail themes and actions being
taken. Complaints can be triangulated through
the use of patient stories at the Board.
At the time of the RRR, the Trust had a significant backlog of
complaints, including complaints dating back to 2010. During the
announced visit, the Trust’s complaints team consisted of two
interim staff members reporting to an interim Director who was not
a member of the Board. The backlog includes delays in
acknowledging complaints.
Several attendees at the King’s Mill Hospital listening event
recorded their frustration at the length of time taken by the Trust to
respond to their concerns and a perceived failure by the Trust to
The Trust is continuing to work to
address all their concerns, acknowledge mistakes and indicate any respond to complaints as well as the
lessons learnt.
validation.
See also KLOE 2(iii) recommended actions
regarding organisational learning.
There was no identified sustainable plan to either address the
backlog or prevent the issue reoccurring. There appeared to be a
focus on validating the number of complaints in the backlog as
opposed to the resolution of the complaints.
Review of the complaints policy found it to not be fit for purpose.
Student nurses at the focus group could not articulate a clear
understanding of the policy or Trust processes.
Despite Trust PALS literature stating that PALS deals with ‘a
problem or concern’, it was confirmed that complaints were
separately dealt with and separately located from PALS. A
separate Trust leaflet ‘Making a Complaint about our services’ did
exist but appeared to be only available on request if a patient knew
to ask for it. This leaflet did make reference to the separate
Complaints Department.
The panel’s test call to the complaints telephone line during the
announced visit was unanswered. Interviews with the complaints
37
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
The Trust was in the embryonic stages
of introducing ‘care and comfort’ round
with plans for 100% implementation in
12 months. A project nurse had been
appointed to oversee it.
Trust to develop a patient experience and
engagement strategy with processes and
systems to ensure effective collecting and
responding to patient feedback, both positive
and where areas of improvement are
identified.
Urgent
staff identified the issue to be one of capacity.
Reporting of complaints and incidents to the Clinical Governance &
Quality Committee consisted only of the number of outstanding
complaints. There was no reporting of complaints issues and
trends to evidence that the Trust was committed to putting things
right for existing and future patients and sought continuous service
improvement.
ii. Patient experience
A number of examples of poor patient experience were identified
during the RRR including:
 Privatisation of patient transport had resulted in issues for
patients including inconsistency of service and issues with
communication.
 The Early Pregnancy Unit is located at the end of a long
walkway immediately above the main entrance which is very
visible to the public.
 EMU was identified to be being used for 12 hours procedures
with no beds available to patients, only chairs, for this
significant period.
 The layout of the new part of King’s Mill Hospital deters staff
from interacting with patients.
 Limited use of the prominent ward display boards was
observed to inform patients and their families/carers about
relevant matters such as patient safety, who to turn to on the
ward with their request/question etc.
 Staff had security badges at waist height but very few staff
were observed to be wearing name badges during the RRR
and patients spoke of being unaware of who was caring for
them.
 Trained staff wore uniforms with dark blue piping on the sleeve
and unqualified had light blue. Staff uniforms did not clearly
High
Staff to wear name badges and clearly
communicate to patients who their consultant
is. Where consultants are changed, the
reasons for the change to be communicated
patients.
Audit times taken for buzzers to be answered
and ensure issues identified are rectified.
High
Review staff uniform policy so that patients
and the public can easily recognise staff levels
by their uniform.
Medium
38
Outstanding concerns based on evidence gathered



Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
distinguish different types of clinical staff from one another
meaning patients found it difficult to clearly identify staff roles
from their uniform.
Phlebotomy procedures were observed on one ward to be
taking place in full view of the ward as the privacy curtain was
not pulled across.
Buzzers were observed to be going unanswered.
On some wards, poor attention to oral hygiene/care was
observed.
Whilst patients and the public attending the listening events
generally spoke of good care once they accessed the Trust’s
services, concerns were raised by patients at both events.
The concerns raised by patients and the public attending the
listening event held at King’s Mill Hospital included the following:
 Concerns over time taken to respond to complaints and
complaints not being acknowledged.
 Delays in follow up as clinic letters and letters to GPs were
delayed.
 Pain management and medicines management concerns.
 Shortage of staff out of hours and at weekends.
 The Trust policy of protected meal times prevented patients’
families from helping feed their relatives.
 Infection control concerns.
 Examples of inappropriate discharge.
The concerns raised by patients and the public attending the
listening event held at Newark Town Hall included the following:
 No clarity of services to be provided at Newark Hospital and a
default of providing services at King’s Mill Hospital.
 A lack of engagement with patients and the public.
 Fluid management and nutrition concerns.
39
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
None noted
Patient communication strategy and processes High
to be developed to ensure patients receive
proper and timely communications from
presenting within the healthcare system with
an illness to resolution of their concern.
It was observed that feedback forms were not well signed within
the Trust and no real time feedback process was in place.
The Trust did not appear to have a patient engagement strategy or
systems to engage with and obtain feedback from patients and
then act upon it.
iii. Communication with patients
Patients interviewed generally spoke of good care at the Trust and
particularly spoke of personalised care at Newark Hospital.
However, a number of issues were noted with communication with
patients, including:
 Some patients being moved between wards with no
explanation.
 Some patients being unaware which doctor was the lead
doctor responsible for their care.
 Some patients were frustrated with the delay in response to
requests for more detailed information relating to diagnosis or
medication changes.
 Some patients had been operated on with no explanation of
what to expect following their elective surgery.
 Examples of incorrect pre operative information being provided
leading to patients going without food and fluid for longer than
was necessary.
40
Workforce and safety
Overview
The two KLOEs in the workforce and safety area focused on workforce planning and staff support, including training.
Examples of good practice were identified in the following areas:

Staff were found to be willing to go the extra mile for patients and even though there are organisational pressures staff remain loyal, passionate and dedicated. Junior
Doctors are actively trying to remain at the hospital or trying to return in the future.

Good staffing levels were observed in paediatrics.
The following areas of outstanding concern were identified:

There are questions about safe medical and nursing staffing levels both in-and out-of hours. Clinical cover is particularly low at the Newark site and the Trust has to
reduce headcount further.

The nursing skill mix is a significant concern at 50:50.

The above are made more significant by the design of the hospital impacting on the ability to provide safe care so staffing levels need to consider the hospital design.

During the RRR, a number of issues were identified for which the root cause was inadequate levels of support staff. There is insufficient administrative support
resulting in poor patient experiences of care (pre-operative, especially) and there are big backlogs in writing letters to patients and GPs

No staff rotation between Newark and King’s Mill developing staff and an apparent absence of appraisals.
Detailed Findings
Workforce planning
KLOE 7: How does the Trust approach workforce planning to ensure that patient safety is managed effectively including skill mix? Is there effective provision for surgical and
medical consultant input following admission?
Good practice identified
Staff were found to be willing to go the extra mile for patient and even though there are organisational pressures staff remain loyal, passionate and dedicated. Junior Doctors
are actively trying to remain at the hospital or trying to return in the future. The care and compassion of clinical staff was noticeable and the specialist nurses were providing a
good level of patient care.
41
Star of the month has been an effective initiative.
Head of IT, when interviewed, had a good grip on the safety and confidentiality aspects of his role and how they could support the Trust.
Good staffing levels were observed in paediatrics.
One ward had received additional trained nurses and the staff interviewed had noted a reduction in falls and complaints. The staff considered they could provide a higher level
of care to these patients.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
i. Nursing and medical staffing levels
Following a CQC review, the
histopathology action plan in
response to the issues noted
had been prepared and
additional staff were being
recruited.
Immediate review of staffing levels at both King’s Mill and
Urgent
Newark Hospitals. The review at King’s Mill Hospital should
consider the patients on the wards, including outliers, and
the layout of the hospital, for example through benchmarking
with other PFI (private finance initiative) hospitals. Both
reviews should account for staff sickness, with particular
review at Newark Hospital with the lower levels of staffing
there.
The review should include understanding of workforce in
relation to performance, for example are workforce levels
impacting on mortality or patient falls and safety.
Urgent
A workforce strategy should be developed as a result and
this should include policies on appropriate use of agency
and locum staff ensuring that they are not putting the
hospital at risk. This should also include adequate support
for junior staff. The Trust to consider expanding the role of
Health Care Assistants to train them formally to provide
more of a support role to nurses.
Significant concerns were noted around staffing levels at
both King’s Mill Hospital and Newark Hospital, particularly
out of hours. Observations included:
 A May 2013 Board position paper on ward staffing
identified that staffing levels were too low. It was further
noted that, as this was a position paper, there had yet to
be a request for additional staffing following identification
of the issue.
 Nursing levels at night were generally two trained and
two untrained on adult wards. It was observed that these
wards often contained high dependency patients but
staffing levels did not appear to be adequate for the
patients of that nature.
 Instances of agency staff / locums being used without
support from staff that understand the hospital. Staff
stated that this had included use of locum staff as the
Medical Registrar at night at both hospitals. This role is
the most senior member of medical staff in the hospital
and should provide support and guidance if needed
throughout the hospital. The Trust states that a locum
Medical Registrar has only been used on an exceptional
basis when no internal cover can be located.
Priority –
urgent,
high or
medium
42
Outstanding concerns based on evidence gathered





Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
Junior doctors spoke, in the focus group, of low levels of
senior support overnight in surgery and orthopaedics.
Patients spoke of concerns over staffing including: low
levels of staffing after 20.00; the long shift hours that
staff worked; how few staff members there were on
some wards; fewer staff on the ward at the weekend with
one patient’s relatives stating that “nothing happens here
from about midday on Friday through to Monday morning
but they say it’s a 24/7 hospital – it isn’t”.
Critical outreach team only operates 8.00-21.00 on
weekdays and 8.30-16.30 at weekends.
Buzzers were observed to be going unanswered.
On a care of the elderly ward, a patient with a
tracheostomy required suction every 30 minutes and was
in a side room, stretching the nurse who also had other
patients to care for.
At King’s Mill Hospital, concerns noted were made more
significant by the design of the hospital which, in a number of
areas, prevented staff visibility of patients from central desks.
At Newark Hospital, the consultant cover was a concern as
both medical speciality consultants with in-patients visited
the hospital on the same days of the week (Tuesday and
Thursday). Out of hours the staffing structure of a single
doctor for both MIU and, if needed, the inpatients, was
considered to be too low. This has led to instances, in the
last year, due to sickness, of there being no medical cover at
the hospital overnight. It was also noted that there may not
be surgical cover overnight at Newark Hospital despite the
surgical activity that is undertaken at the hospital during the
week. Furthermore, staffing of a single anaesthetist and
surgeon for surgery may not provide adequate cover if there
are complications.
43
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
None noted
A review of the nursing skill mix with immediate plans to
Urgent
ensure that the skill mix in place is adequate to provide safe
patient care. To utilise national and professional
benchmarks to determine appropriate levels, also taking
account of the facilities and environment at each hospital.
To also ensure attention is paid to the recommendations and
findings of the Francis report.
See above regarding urgent review of staffing levels.
The above was all identified alongside the Trust CIP to
reduce staffing in 2013/14.
There appeared to be no medical workforce strategy despite
the challenges of 7 day working and the need to increase
senior medical presence. Job planning had not been
delivered consistently each year.
Also note the concerns over anaesthetics reported above at
KLOE 4.
ii. Nurse skill mix
The Trust stated that nurse trained to untrained ratios were
currently 50:50 on the general wards. The minimum that the
RRR panel would expect is 60:40 with a preference for
65:35.
iii. Support staff levels
The Trust had an extensive
review in place to address the
During the RRR, a number of issues were identified for which backlog of clinic appointment
the root cause was inadequate levels of support staff. These letters with an action plan to
issues included:
clear the backlog by 31 July
 Backlog of complaints including acknowledgement of
2013.
complaints.
 Patients were being verbally told of surgery dates but
then experiencing long delays before receiving the letter The Trust is working with GPs to
review the information currently
confirming the date. The Trust confirmed a backlog of
provided on the electronic
4,000 clinic letters as at the end of June 2013.
discharge summaries and
 Patients consistently spoke of significant delays to
content of clinic letters.
discharge letters being received by GPs.
Support staff levels and roles to be reviewed. Sustainable
plans to be put in place for complaints, discharge letters,
clinic appointments and adequate security. Increase in the
pace of change to address the backlogs.
Urgent
44
Outstanding concerns based on evidence gathered


The staff focus group agreed that insufficient medical
secretaries and administration staff was resulting in poor
patient care.
Security at night at Newark Hospital was a concern.
Doors are not locked to the hospital with just two nurses
on the night shift. During the unannounced RRR visit, a
door to a ward was observed to be unlocked and the
RRR panel members were able to enter the ward without
being admitted by staff.
Key planned improvements
Recommended actions
Priority –
urgent,
high or
medium
The Trust states it is increasing
support staff whole time
equivalents (WTE) by 25 WTE
and investing £450,000.
Staff support including training
KLOE 8: How does the Trust support its staff including with adequate training?
Good practice identified
Interviews with staff identified a good level of knowledge of safeguarding processes.
Good mentorship for student nurses.
Monthly junior doctors’ forum meant that junior doctors felt that their views were listened to. A designated doctor attends, follows up concerns and then feeds back to the
group.
Staff interviewed generally said that the Trust had shown good levels of investment with education, training and induction programmes. Staff generally felt valued by the
Trust.
45
Outstanding concerns based on evidence gathered
Key planned
improvements
Recommended actions
i. Staff development
None noted
Regular appraisals and personal development plans High
to be provided to all staff and review of achievement
of these by the Board.
The following issues were identified with staff development during the RRR:
 Discussions with staff identified there was little or no rotation of staff
between King’s Mill and Newark Hospitals.
 The Associate Medical Director had not received an appraisal for over 18
months.
 EAU nurses attending the focus group reported that they had not been
appraised since 2007 and had not had any development activities in that
period too. In their ward there was a 2% appraisal rate.
Trust to introduce staff rotation between King’s Mill
Hospital and Newark Hospital.
Priority –
urgent, high or
medium
Medium
46
5. Conclusions and support required
Conclusions
This is a Trust starting on a journey with the very recent appointments of Chair, Chief Executive and new Non Executive Directors. When the Trust was placed in breach with
Monitor for finance and governance in October 2012, a new interim Chair and CEO were put in place by Monitor to oversee the actions for improvements of the Trust. During
this time until June 2013, the Trust has had a rapid improvement regime and priorities were made to meet the breach notices, therefore some areas were not adequately
given attention, such as patient experience.
The emergency department was extremely busy on both the announced and unannounced visit with high volumes of patients attending. Although extremely busy the unit
seemed calm and well organised with only one observed breach which was for clinical reasons not operational.
The panel observed that the Trust was welcoming and all staff that they met were engaging, committed and loyal to the Trust. Staff were found to be willing to go the extra
mile for patients and even though there are organisational pressures staff remain loyal, passionate and dedicated. High-quality, personalised care throughout the Trust was
reported by many patients and families. Generally patients felt, that once they were seen, they were given very good care.
Substantive appointments have been made to Board including four new Non Executive Directors commencing in May 2013 and the Chief Executive and Chair taking up their
posts on 10 June 2013. The final Non Executive Appointment will become substantive in November 2013 and was acting in a Non Executive Advisor role until that date. The
June 2013 Clinical Governance & Quality Committee was well chaired and the Non Executive Directors attending challenged the Executives effectively during the meeting.
Evidence was identified of an outward looking Trust working with neighbouring trusts and sharing good practice and joint working with other organisations to improve A&E.
The Trust had sought external review of both governance and finance following being placed in breach with Monitor and was open to this review.
There were examples of excellent ward leadership observed. The stoma nurses and colorectal cancer nurse specialists were cited to provide excellent continuity of care,
especially in combination with the ambulatory clinic on the Surgical Assessment Unit, if there are concerns. The outreach team are very highly regarded by trust staff.
No issues were identified during the course of the review that were considered by the panel, with the support of the CQC representative on the panel, to need immediate
escalation and resolution.
47
Urgent priority actions for consideration at the risk summit
Problem identified
Recommended action for discussion
1. Complaints and support staff levels (see detailed
finding on pages 36 to 37)
The backlog of complaints should be cleared alongside development of Capacity support to clear the
a sustainable approach to acknowledging and responding to
backlog.
complaints going forward. This should be lead by a clinical Executive
member of the Board.
At the time of the RRR, the Trust had a significant backlog
of complaints, including complaints dating back to 2010.
During the announced visit, the Trust’s complaints team
consisted of two interim staff members reporting to an
interim Director who was not a member of the Board. The
backlog includes delays in acknowledging complaints.
Support required by the Trust
There was no identified sustainable plan to either address
the backlog or prevent the issue reoccurring.
During the RRR, a number of issues were identified for
which the root cause was inadequate levels of support staff.
This was again noted in the context of a 2013/14 CIP to
reduce headcount at the Trust and plans being
implemented at the time of the RRR to downgrade a
number of Band 4 secretaries to Band 2.
2. Nursing and medical staffing levels and nurse skill
mix (see detailed finding on pages 41 to 42)
Significant concerns were noted around staffing levels at
both King’s Mill Hospital and Newark Hospital, particularly
out of hours.
At King’s Mill Hospital, concerns noted were made more
significant by the design of the hospital which, in a number
of areas, prevented staff visibility of patients from central
desks.
At Newark Hospital, the consultant cover was a concern as
both medicine speciality consultants with in-patients visited
the hospital on the same days of the week (Tuesday and
Immediate review staffing levels at both King’s Mill and Newark
Workforce review and planning
Hospitals. The review at King’s Mill should consider the patients on the support.
wards, including outliers, and the layout of the hospital, for example
through benchmarking with other PFI hospitals. Both reviews should
account for staff sickness, with particular review at Newark with the
lower levels of staffing there.
The review should include understanding of workforce in relation to
performance, for example are workforce levels impacting mortality or
patient falls and safety?
A review of the nursing skill mix with immediate plans to ensure that
the skill mix in place is adequate to provide safe patient care. To utilise
national and professional benchmarks to determine appropriate levels,
48
Problem identified
Recommended action for discussion
Thursday). Out of hours the staffing structure of a single
doctor for both MIU and, if needed, the inpatients, was
considered to be too low. This has led to instances, in the
last year, due to sickness, of there being no medical cover
at the hospital overnight. It was also noted that there may
not be surgical cover overnight at Newark Hospital despite
the surgical activity that is undertaken at the hospital during
the week. Furthermore, staffing of a single anaesthetist and
surgeon for surgery may not provide adequate cover if there
are complications.
also taking account of the facilities and environment at each hospital.
To also ensure attention is paid to the recommendations and findings
of the Francis report.
Support required by the Trust
A workforce strategy should be developed as a result and this should
include policies on appropriate use of agency and locum staff ensuring
that they are not putting the hospital at risk. This should also include
adequate support for junior staff. The Trust to consider expanding the
role of Health Care Assistants to train them formally to provide more of
a support role to nurses.
The above was all identified alongside the Trust CIP to
reduce staffing in 2013/14.
It was further noted that the Trust stated that nurse trained
to untrained ratios were currently 50:50 on the general
wards. The minimum that the RRR panel would expect is
60:40 with a preference for 65:35.
3. Fluid management (see detailed finding on pages 33 to
34)
Training supported by frequent audits of fluid management processes
and improvements in fluid management.
Fluid management training and
sharing of good practice.
Throughout the RRR, the panel identified concerns with
fluid management throughout the Trust, through
observations and speaking with patients. Review of fluid
charts identified issues with the majority reviewed including:
no records of fluid for patients for a over a day; fluid records
not completed; patients not being risk assessed for fluid on
arrival; and fluid balance charts not being totalled.
In addition, the ‘Red Jug’ initiative being used for patients
with a need for assistance with fluid was not observed to be
effective – many patients with an apparent need for
assistance had not been identified.
49
Problem identified
Recommended action for discussion
Support required by the Trust
4. Strategic direction (see detailed finding on pages 18 to
19)
The Trust needs to determine and clearly articulate and communicate
its strategic direction.
Board development and strategic
planning support.
Whilst we observed a number of good practices throughout
the Trust, these appeared to be ward level specific and siloed. There was an absence of a strong strategic direction
and Trust level working. This was confirmed by a number of
nurses interviewed that if felt like wards worked in silos and
no one had an umbrella role across the Trust.
Immediate discussions to consider including Nottingham University
Hospitals as a full partner in the Mid Nottinghamshire Review.
All the Trust’s strategic plans and strategies were either in
draft or not yet in place. There were no robust clinical or
quality strategies in place at the Trust at the time of the
RRR. The Trust had no nursing strategy and nurses
attending the focus group were unclear as to the strategic
priorities of the Trust and their contribution to improving
standards and quality.
It was also unclear how the Trust was engaging with their
local healthcare economy. Furthermore, the panel saw
limited engagement with staff and the local population on
strategy.
Whilst the Mid Nottinghamshire Review was underway
across the local healthcare economy, the strategy lacked
the full engagement of a tertiary centre. Without this the
options for the Trust are limited.
5. Newark Hospital – strategy, facilities and governance
(see detailed findings on pages 19, 20 and 32)
There was an absence of a clear strategy for Newark
Hospital with no clearly articulated future use for the
hospital and best use of the facilities there.
Major operations (joint replacements) are carried out at
Newark Hospital including on a Friday morning. These
operations have the potential for serious complications and
The Trust needs to determine and clearly articulate and communicate
its strategic direction on the use of the facilities at Newark Hospital.
Ensure that the facilities are adequate for the services to be provided
at Newark and keep under constant review to provide ongoing
assurance.
The Newark strategy needs to determine the future of the hospital
working with the wider health community and social care and the
public.
Board development and strategic
planning support.
Data analysis support.
Decision on long term future of use
of Newark Hospital.
50
Problem identified
Recommended action for discussion
the hospital does not have adequate facilities should
serious complications arise. For example, there is no blood
bank at the hospital.
In view of the concerns about the safety of care at Newark Hospital, it
should be identified as a separate site within the Trust governance
structures. The Executive lead for Newark Hospital needs to be more
visible at the hospital and the responsibility clearly communicated
throughout the Trust.
Concerns were identified with the effectiveness of the
governance of the hospital with a governance group
meeting at Newark Hospital but with an apparent self review
agenda and no clear way for this group to feed into the
Trust governance structure other than send information to
three different governance groups as relevant. There was
limited Executive team engagement with Newark Hospital
with staff there speaking of limited Executive team presence
at the site.
6. Development of a focus on quality at Board level (see
detailed finding on pages 17 to 18)
During the RRR process, the panel observed that that
Board level focus on quality and the patient was still
developing. A number of plans were described by members
of the Board as being required by Monitor, rather than being
needed for improved levels of quality and safety, and there
was recognition that the Trust has historically been focused
on finance rather than quality.
Support required by the Trust
In view of the on-going concerns about mortality rates for Newark
residents, the CCG and Trust need to set up a group to review the data
and understand if there are any underlying concerns that should be
addressed.
The Board must set a tone from the top of the focus on quality and the
patient. The current focus on mortality to be widened to consider
quality and safety. Sufficient time should be given to quality at the
Board.
Board development support.
The quality governance framework was seen as a parallel
exercise by the PMO opposed to embedding as a collective
Board responsibility.
7. Ward performance information and organisational
learning (see detailed findings on pages 25 to 26 and
pages 26 to 27)
Concerns were noted around performance information
including the absence of ward level performance measures
and information. Staff were generally unable to articulate
performance levels on their own wards, for example the
number of falls on the ward in the last month. Interviews
Consistent ward dashboards across the Trust presenting relevant ward Performance information support.
level performance measures and up to date performance achieved.
Ward dashboards to be supported by ward level assurance processes Ward assurance support and sharing
to ensure the accuracy of the data, for example quarterly data audits.
of good practice.
Systems to ensure organisational learning from good practice,
concerns and incidents lead by an Executive.
Organisational learning support and
sharing of good practice.
51
Problem identified
Recommended action for discussion
Support required by the Trust
Risk assess all patients prior to move or transfer supported by
appropriate training.
Patient tracking and bed
management support.
Review of handover times to ensure there is time to handover all
patients on the ward adequately.
Workforce planning support.
Trust to develop a patient experience and engagement strategy with
processes and systems to ensure effective collecting and responding
to patient feedback, both positive and where areas of improvement are
identified.
Patient engagement support and
sharing of good practice.
An updated, comprehensive NEWS policy should be developed and
communicated to staff.
n/a
with staff generally identified that staff were unaware of
performance levels and did not feel ownership of them.
Examples were noted during observations of out of date
ward performance measures on display on wards or
template reports with no information / data displayed.
Concerns were noted with the processes in place for
organisational learning.
8. Concerns over patient locations and high numbers of
patient moves (see detailed finding on pages 28 to 29)
During the RRR process, concerns were identified over the
number of patient moves and outliers within the Trust.
9. Handovers (see detailed finding on page 29)
It was identified that ward staff only had 20 minutes to hand
over patients on shift changes. Observation of a handover
during the unannounced saw that ward staff had to split into
two teams for the handover period to enable there to be
sufficient time to handover all the patients on the ward. This
meant no one had an overview of all the patients on the
ward and each half of the ward was being effectively staffed
by only one trained nurse member and one untrained.
10. Patient experience (see detailed finding on pages 37 to
39)
A number of examples of poor patient experience were
identified during the RRR.
The Trust did not appear to have a patient engagement
strategy or systems to engage with and obtain feedback
from patients and act upon it.
11. NEWS roll out (see detailed finding on page 33)
At the time of the visit, NEWS had been introduced at the
52
Problem identified
Recommended action for discussion
Support required by the Trust
Staff who blow the whistle should not be monitored. The policy should
be updated to confirm this.
n/a
Support staff levels and roles to be reviewed. Sustainable plans to be
put in place for discharge letters, clinical appointments and radiology
reporting. Increase in the pace of change to address the backlogs.
Capacity support to clear the
backlog.
Trust and staff interviewed spoke of the revised process.
The only policy that the RRR panel identified was the old
policy in tracked changes – no revised policy was identified
to support the introduction of a revised process.
12. Whistle blowing policies (see detailed finding on page
26)
The whistle blowing policy contained no approval or review
date. The policy also appeared to imply that staff who blew
the whistle would be monitored as it contained the
statement “A file of any whistle-blowing concern will be kept
on the member of staff’s personal file”.
13. Supporting structures and services (see detailed
findings on pages 29 to 30 and pages 43 to 44)
A number of concerns were noted with the infrastructure in
place and use of it to support good patient flow and good
quality care, including:
 Patients were experiencing significant delays in
receiving discharge letters and clinic appointments.
 The Trust has over 2,000 GP plain films or Neuro MRIs
to be reported on as stated at the Clinical Governance&
Quality Committee in June 2013.
Workforce review and planning
support.
53
Appendices
54
Appendix I: SHMI and HSMR definitions
HSMR definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the
hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)
for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for a
case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of
palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify if
variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when
these have been crossed is performance classed as higher or lower than expected.
SHMI definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI
follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for
potential deviations away from regular practice.
How does SHMI work?
1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data.
2) The SHMI is the ratio of the observed number of deaths in a trust vs. expected number of deaths over a period of time.
55
3) The Indicator will utilise five factors to adjust mortality rates by:
a. The primary admitting diagnosis.
b. The type of admission.
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities).
d. Age.
e. Sex.
4) All inpatient mortalities that occur within a hospital are considered in the indicator.
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted using a Random Effects funnel plot.
Some key differences between SHMI and HSMR
Indicator
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are included, which Yes, all deaths are included.
varies significantly dependent upon the services provided
by each hospital.
When a patient dies, how many times is this counted?
If a patient is transferred between hospitals within two
days, the death is counted multiple times.
One death is counted once, and if the patient is
transferred, the death is attached to the last
acute/secondary provider.
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Yes.
No.
Does the indicator consider where deaths occur?
Only considers hospital deaths.
Considers in hospital deaths, but also those up to 30
days post discharge anywhere too.
Is this applied to all health care providers?
Yes.
No, does not apply to specialist hospitals.
56
Appendix II: Panel composition
Panel role
Name
Panel Chair
David Levy
Patient / Public representative
Gary Robinson
Patient / Public representative
Norma Armston
Patient / Public representative
Jenny Cairns
Junior Doctor
Mahesh Kudari
Doctor (Surgeon)
Esther Fine
Doctor
Paul Molyneux
Doctor
Anna Lipp
Student Nurse
Carl Shooter
Board Level Nurse
Liz Rix
Senior Nurse
Liz Hogbin
Senior Nurse
Matt Sandham
Trust Senior Manager
Francesca Thompson
CQC
Carolyn Jenkinson
57
Panel role
Name
Regional Support
Finola Munir
Regional Support
Graeme Jones
Observer, CCG representative
Elaine Moss
Observer, Area Team
Aly Hulme
Observer
Mike Richards
Observer
Keziah Halliday
58
Appendix III: Interviews held
Interviewee
Date held
Paul O’Conner, Chief Executive
17 June
Sean Lyons, Chair (from 10 June 2013)
Chris Mellor, Chair (October 2012 to 9 June 2013)
17 June
Dr Simon Stinchcombe, Assistant Medical Director of Patient Safety
17 June
Susan Bowler, Director of Nursing and Quality
17 and 18 June
Jacqui Tuffnell, Director of Operations
17 and 18 June
Dr Peter Marks, Incoming Chair of Clinical Governance & Quality Committee (from May 2013)
17 June
Outreach Team:
Sheila Hennessy, Specialist Nurse
Richard Corderoy, Critical care outreach
18 June
PMO Team:
Shirley Clarke, Head of Programme management
Yvonne Simpson, Clinical Advisor
18 June
Clinical Directors:
Dr Richard Hind, CD for Surgery and Plan care
Dr Shrikant Ambalkar, CD for Diagnostics and Rehab
Dr Anne-Louise Schokker, CD for Medicine and Emergency Care
18 June
Karen Fisher, Director of HR and OD
18 June
Quality Team:
Amanda Callow, Deputy Nurse Director
Sarah Addlesee, Patient Safety Lead
Denise Berry, Clinical Governance Advisor
Sarah Banks, Assistant Director of Nursing for CQC
Ian Greenwood, Interim Director of Strategy
18 June
59
Interviewee
Date held
Shanon Wheeler and Jane Cook , Colorectal cancer nurse specialists
18 June
Richard Scott, Head of Medical Inventory
18 June
Manjit Obrari, Ex Chair of Clinical Governance & Quality Committee (Oct 2012 to May 2013)
18 June
Eddie Olla, Director of Health Informatics
Ruth Lloyd, Corporate Governance Manager
18 June
A follow up interview was held following the announced visit:
Interviewee
Ian Greenwood, Interim Director of Strategy
Date held
20 June
The following interviews were held following the announced visit due to the interviewees being on leave during the week of the visit:
Interviewee
Date held
Dr Nabeel Ali, Executive Medical Director
25 June
Fran Steele, Chief Financial Officer
25 June
60
Appendix IV: Observations undertaken
King’s Mill Hospital
Observations were undertaken in the following areas of King’s Mill Hospital:
Observation area
Date of observation
A&E
17 and 18 June
Emergency Assessment Unit
17 and 18 June
Ward 31 – surgical ward
17 June
Ward 51 – healthcare of the elderly ward
17 June
Ward 52 – healthcare of the elderly ward
17 June
PALS
18 June
Complaints department
18 June
Fracture clinic observation
18 June
Maternity
18 June
NICU
18 June
Pathology
18 June
Ward 53 – stroke ward
18 June
Outpatients
18 June
X-ray
18 June
Gynaecology
18 June
ITU
18 June
Ward 24
18 June
61
Ward 53
18 June
Ward 25 – paediatrics
18 June
Labs
18 June
Pharmacy
18 June
Ward 36 – escalation ward (closed)
18 June
Ward 35 – escalation ward
18 June
Ward 34 – escalation ward
18 June
Ward 43 – respiratory ward
18 June
Ward 44 – respiratory ward
18 June
Theatres
18 June
Day surgery unit
18 June
Ward 11 – orthopaedic ward
18 June
Ward 12 – orthopaedic ward
18 June
Observations were also undertaken of the following meetings:
Meeting observed
Bed meeting at King’s Mill Hospital, 9am (held in the
capacity room)
Date of observation
18 June
A panel member also observed the following meeting following between the announced and unannounced site visits:
Meeting observed
Date of observation
62
Clinical Governance & Quality Committee
19 June
Further observations were undertaken as part of the unannounced site visit, see Appendix VII.
Newark Hospital
Observations were undertaken in the following areas of Newark Hospital:
Observation area
Date of observation
Sconce Ward
17 June
Minor Injuries Unit
17 June
Fernwood Unit (intermediate care)
17 June
Mercia doughty pre-operative assessment unit
17 June
Theatres
17 June
Minster Ward
17 June
Further observations were undertaken as part of the unannounced site visit, see Appendix VII.
63
Appendix V: Focus groups held
Focus group invitees
Focus group attendees
Date held
Doctors
7 doctors from medicine and surgery (no attendees from the emergency department or gynaecology).
17 June
All staff
35 members of staff from a range of departments including facilities.
17 June
Nurses
5 nurses from various wards.
18 June
Junior doctors
8 junior doctors (medical and surgical).
18 June
Trainee nurses
6 student nurses from various wards.
18 June
Matrons
10 senior nurses from various wards.
18 June
Trust Governors
7 governors including staff and public governors.
18 June
64
Appendix VI: Information available to the RRR panel
The following documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the announced site visit. Whilst the
documents were not reviewed in detail, they were available to the panellists to validate findings.
Committee structure for assuring quality & safety
Clinical Governance and Quality Committee Terms of
Reference version 3
Clinical Management Team Terms of Reference
version 1
Risk Committee Draft Terms of Reference version 1
Trust Mortality Group Terms of Reference version 3
Annual Plan submission to Monitor 2012/13
Clinical Governance & Quality Committee agenda and
papers for meeting of 20 February 2013
Clinical Governance & Quality Committee agenda and
papers for meeting of 21 March 2013
Clinical Governance & Quality Committee agenda and
papers for meeting of 17 April 2013
Management structure diagram
Director of operations structure
CV Paul O’Connor, Chief Executive
CV Nabeel Ali
CV Lucy Dadge
CV Karen Fisher
CV Jacqui Tuffnell
CV Fran Steele
CV Susan Bowler
Job description Chief Executive
Job description Executive Medical Director
Job description Executive Director of Nursing & Quality
Job description Executive Director of Human
Resources and Organisation Development
Job description Director of Strategic Planning and
Commercial Development
Job description Director of Operations
Job description Director of Finance and Performance
Job description Head of Corporate Services
Board papers February 2013
Board papers March 2013
Board and Quality Governance: Recommendations
and Initial Action Plan – April 2013
Quality Report 2011/12 – Final 22 June 2012
65
Risk Committee agenda and papers March 2013
D&R All Risks – April 2013
D&R High Risks – April 2013
EC&M Risk Register – 19 April 2013
Enc H Board Assurance Framework – November 2012
PC&S Open Risks – April 2013
Corporate and Central Services Open High Risks – 15
March 2013
Clinical audit annual report 2011 to 2012 and clinical
audit forward plan 2012 to 2013
2013/14 Trust wide clinical audit forward plan – 2 April
2013
Trust Mortality Group Meeting Minutes 28 January
2013
Trust Mortality Group Meeting Agenda 25 February
2013
Trust Mortality Group Meeting Minutes 25 February
2013
Trust Mortality Group Meeting Agenda 25 March 2013
Trust Mortality Group Meeting Minutes 25 March 2013
Dr Foster mortality report February 2013 including
November 2012 discharges
Dr Foster mortality report March 2013 including
December 2012 discharges
KPMG Project Hylands Financial Governance and
Strategic Sustainability Review – 30 November 2012
Cancer Action Team Cancer Peer Review Report 2011
to 2012 – June 2012
bsi Assessment Report Medical Equipment
Management Department – 5 February 2013
BSI Assessment Report Medical Equipment
Management Department – 10 May 2012
The Royal College of Pathologists Review of cellular
pathology governance, breast reporting and
immunohistochemistry – 20 February 2013
SSNAP Acute organisational audit report – November
2012
Nottingham University Hospitals NHS Trust Annual
RPA audit report X-ray department, Ashfield
Community Hospital :13 November 2012 – 24
December 2012
Nottingham University Hospitals NHS Trust External
audit of unlicensed pharmacy aseptic preparation at
King’s Mill Hospital – 8 April 2013
Royal Free Hampstead NHS Trust Summary report of
the newborn hearing screening programme risk
assessment and quality assurance in north
Nottinghamshire – July 2012
Audit Commission Payment by results data assurance
framework – February 2013
Safeguarding adults self assessment and assurance
framework 2011
66
CQC inspection report King’s Mill Hospital: 10 October
2012
CQC Patient survey report 2012
External review process of Ultrasound Nuchal
Translucency measurements used in the calculation for
Downs Syndrome screening (paper)
NHS Nottinghamshire County Maternity Service Visit 5
April 2012
NHS East Midlands Annual audit of midwives 2011/12
– 21 February 2012
NHS Midlands and East Review of pharmacy services
– 25 February 2013
NHS Midlands and East Report of midwifery staffing
review – 9 August 2012
NHS Midlands and East Completion of self
assessment and assurance framework feedback – 30
April 2012
NHS Trent Perinatal Network Network review Neonatal
Unit King’s Mill Hospital – 8 October 2012
NHS Litigation Authority NHSLA risk management
standards for NHS trusts providing acute services
2011/12 Level 1 – February 2012
PwC Review of Board and Quality Governance – 31
January 2013
PwC Mortality review – 3 January 2013
CHKS Clinical coding audit for information governance
– February 2013
General Medical Council Target Check 11 January
2013
Pathology external visits reports paper 2012 to 2013
Ariotti Doe & Associates – February 2012
CIP 2012/13 CIP schemes by division
CIP 2013/14 scheme status report – 18 April 2013
Programme Board Process Quality Impact
Assessments 4th draft – 19 April 2013
Advisor working practice progress chart
CHC and social services flowchart
Mansfield and Ashfield CHP – Care of the Elderly
Workstream Highlight report: 28 February 2013 to 17
April 2013
Intermediate Care Services Mansfield and Ashfield
Quarterly Report October 2012 to December 2012
NHS Bassetlaw Trauma and orthopaedics pathway
Monitoring form Q4 2012/13
Trust analysis of mortality including any detailed
analysis.
Complaints and incidents policy and latest report.
Escalation policies.
Trust mortality terms of reference
Dr Foster Mortality Alert review - January
Complaints policy
Incidents (recording) policy
Observation and augmented care assessment tool
policy
67
Dr Foster Mortality Alert review - February
Policy for reporting and management of Serious
Incidents in the East Midlands
Policy for the assessment of acute illness severity
in adult patients; monitoring vital signs and using a
physiological track and trigger score
Guideline for the use of MEOWS
Inpatient capacity and flow framework
trust capacity and flow escalation procedures
Operational policies for surgery.
End of life care policies.
Liverpool Care Pathway for the dying patient
Guideline for the management of patients
prescribed Clopidogreal prior to Elective surgery
Guideline for the management of patients with
diabetes during Surgery
Guideline for the management of hypertensive
patients presenting elective surgery
Guideline for the use of phenylephrine to treat
spinal anaesthesia induced hypotension during
caesarean section by Sherwood Forest Hospital
trust Obstetric Anaesthetists
Kings Mill Hospital Day Case Unit operational policy
Post operative observation and discharge following
laparoscopic surgery
Critical care operational policy
Operational policy for pre-operative assessment
unit
Operational policy for the main and day case
operating departments at King's Mill Hospital
Policy for the transfer of patients back to the ward
having undergone a surgical or anaesthetic
procedure in Kings Mill Theatres
Operational policy for the operating department at
Newark General Hospital
Policy for the care of sharps in perioperative
environment
Guideline for the care of patients who die while in
the operating department
Policy for the swab, sharps, instrument and
sundries counts in the operating departments
Policy for the safe management of specimens when
Patient feedback surveys.
Friends and family test May 2013
Friends and family test April 2013
Friends and family test 2012-13
Kings Mill Hospital Out patient experience survey - all
clinics - January 2013
Kings Mill Hospital Out patient experience survey - all
clinics - February 2013
Kings Mill Hospital Out patient experience survey - all
clinics - March 2013
Kings Mill Hospital Out patient experience survey - all
clinics - April 2013
Kings Mill Hospital Ward Visitor Experience - April
2013
Sherwood Forest Hospitals Pilot Project - Clincial
Patient Experience (Respiratory) - April 2013
Newark Hospital Out Patient experience survey January 2013
Newark Hospital Out Patient experience survey february 2013
Newark Hospital In Patient experience survey January 2013
Newark Hospital In Patient experience survey february 2013
Newark Hospital In Patient experience survey - March
2013
Newark Hospital In Patient experience survey - April
2013
68
taken in the operating departments
Policy for the care of the surgical patients with body
piercings and associated jewellery
Policy for registered nurse or operating department
practioner acting in the role of Advanced Scrub
Practioner (First Assistant) in the absence of a
second medical or dental practioner
Policy for registered nurse or operating department
practioner acting in the operating department
undertaking the scrub role and assisting in the postAnaesthetic recovery room
Policy for the checking of patients on the wards
prior to transfer to the operating theatre and the
checking of patients into the operating theatres
following transfer from the ward
ORMIS roles and responsibilities in relation to the
operating department
Policy and procedure for the positive identification
of patients
Trust-wide protocol pre-operative starvation of
patients aged 3 years and above
Patient Theatres Safety briefing - surgical checklist
Surgical Assessment Unit operational policy
World Health Organisation (WHO) Checklist.
Patient Theatres Safety briefing - surgical checklist
See 2.1 as well - Patient Theatres Safety briefing surgical checklist
Quality Impact Assessment process and reporting for
Cost Improvement Plans.
Quality Impact Assessment completiong guide and
form
Minutes of meeting on Monday 15 April 2013, including
QIA discussions
Template referral form.
SFHFT Surgical Safety Checklist
Hospital at night Call Log (two versions)
Bedstate/ site report
Daily event / log sheet
Template handover form.
Maternity Ward list
Nursing assessment booklet for adult inpatients
EAU handover - staff record
EAU handover - patient record
Safeguarding policies (adults and children).
Patient experience and engagement strategy.
None
Safeguarding adults policy
Safeguarding children and young people policy
Raising conerns - Whilstleblowing policy and
procedure
69
Whistle blowing policy.
NHS Mansfield and Ashfield Clinical Commissioning
Group & Newark and Sherwood Clinical
Commissioning Group HSMR Briefing / Assurance
Pack Sherwood Forest Hospitals NHS Foundation
Trust – May 2013
NHS Newark and Sherwood Clinical Commissioning
Group Newark Hospital Briefing for Members – 3 June
2013
Mid Nottinghamshire NHS Integrated Care
Transformation Programme (ICTP) – April 2013
Briefing on complaints management - June 2013
NHIS: On overview June 2013
Newark Hospital - briefing for Members 3rd June 2013
HSMR Briefing / Assurance Pack - May 2013
Mid Nottinghamshire NHS Integrated Care
Transformation Programme (ICTP) - April 2013
The Guardians of care quality booklet
Relative risk HSMR mortality outcomes benchmarking
papers - June 2013
List of anaesthetic practises that should be monitored
in general surgery
NHIS leaflets:
General Surgery Service line Scorecard - October
2012
NHIS Virtual Desk Infrastructure leaflet
NHIS SystmOne ED leaflet
NHIS Trial CSC Telemedicine Solution leaflet
SFHFT Draft Revenue Equipment List - Replacement
NHIS Professional Services function leaflet
list 2013/14
New NHIS Customer Portal leaflet
NHIS Quantifiable benefits the essence of business
change and business management leaflet
BMS Mobile Clinic Working station solution - case study
NHIS Meeting point; leader and participant guide
NHIS Personal Information Security guidance
Kings Mill and Newark Typing Backlog trajectory at
18/06/13
Patient Administration Consultation drop-in sessions
30/31 May 2013
Clinical Administration 'Patient Pathway coordinator
Patient Administration consultation structures
patient Administration project group - next steps
14/06/2013
Pressure Ulcer prevention plan
70
model' Staff consultation session April 2013 - slides
12/06/2013
Nursing and Midwifery objectives in 2012 and 2013
Royal College of Anaesthetists review of Sherwood
Forest Hospitals
Adult Nursing Core Care Plan form
Sherwood Forest Hospitals; information for patients
Day case operation on Minster Ward at Newark
Ward Assurance Matrix - April 2012-March 2013
Primary Angioplasty patient pathway for Nottingham
University Hospitals
Consent for your operation, procedure, investigation or care
Anaesthetics overview A11
Pain relief after surgery A04
Reducing your risk of developing a bloody clot DP01
Pressure ulcer prevention
Total knee replacement OS02
Your admission to King's Mill hospital
Day case operation on Kings Mill
Occupational therapy department post-operative
assessment
Antibiotic Prophylaxis for Orthopaedic Surgery
NJR Patient Consent Form
Surveillance data sheet; hip and knee replacement and
neck of femur repair
NJR K1 Knee Primary form
Trent and Wales Arthoroplasty audit group - Knee
record
Guidelines for the selection of elective surgical patients
for Newark hospital
Anaesthetic Service Line Scorecard February 2013
Position paper on ward staffing levels in Nursing - May
2013
Position paper on ward staffing levels in Nursing Executive Summary - May 2013
CIPs summary
Director of nursing PowerPoint presentation from Trust
Presentation
71
Cancer peer Review - especially colorectal cancer
Integrated performance dashboard - referred to by the
Director of Nursing
Ward nursing quality dashboard - referred to by the
Director of Nursing
Audits of sepsis bundle
List of CIPs in 12/13 and for 13/14 with values for
which Q/A was not deemed necessary
Handover of care policy or arrangements (Newark and
Community)
Patient experience strategy/ approach to measuring
Board paper or discussion on stroke (paper and
minutes from most recent version)
Nursing strategy
Tracheotomy policy
Organisational chart of nursing
Management reporting structures (including Newark)
Governance structures below Board
Compliance report and any information by ward
Report on outliers
PwC Governance and KPMG Finance reports from
May
Learning Disability Patient Policy
Minutes of the medicines review group
Royal College of Anaesthetists Review
Papers for the Quality and Governance meeting on the
19th June
Resuscitation post cardiac arrest/ deteriorating patient
audit
Criteria to safely accept a patient with a tracheotomy
onto a ward
72
Appendix VII: Unannounced site visit
Agenda item
Panel pre-meet (off site)
Entry into King’s Mill and Newark Hospitals through the A&E and MIU respectively – entry announced to site managers
Observations undertaken of the following areas at King’s Mill Hospital:
 A&E
 CDU
 EAU including medical staff on call.
 Ward 52 – dementia ward
 Ward 51
 Ward 36 (closed)
 Ward 35
 Ward 11
 Ward 12
 Clinic 15 (closed)
 Ward 42
 Ward 41 including observation of the outreach team
 Ward 22
Observation of the F2 on call was also undertaken and an interview with the hospital site manager.
Observations undertaken of the following areas at Newark Hospital:
 MIU
 Sconce ward
 Minster ward
Panel left the hospital sites and announced exit.
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